Why a proven tool to com­bat opi­oid abuse is un­der­uti­lized by health­care pro­fes­sion­als

Modern Healthcare - - NEWS - By Steven Ross John­son

Dr. Stu­art Git­low had to move his prac­tice twice be­cause neigh­bor­ing pro­fes­sion­als com­plained about the ap­pear­ance of the peo­ple he treated. Other doc­tors say pro­vid­ing med­i­ca­tion-as­sisted ad­dic­tion re­cov­ery treat­ment opens them up to reg­u­la­tory au­dits.

As the im­me­di­ate past pres­i­dent of the Amer­i­can So­ci­ety of Ad­dic­tion Medicine’s board of direc­tors, Git­low can at­test to the dif­fi­culty in car­ing for ad­dicts.

So he was luke­warm about the White House’s new­est plan to com­bat the opi­oid abuse epi­demic. In a pro­posed rule, HHS would al­low pa­tient loads to be dou­bled for doc­tors who pre­scribe buprenor­phine.

The move to bump pa­tient lim­its from 100 to 200 was met with mixed re­ac­tions by health pro­fes­sion­als and pa­tient ad­vo­cates, who say physi­cians of­ten shy away from med­i­ca­tion-as­sisted treat­ment be­cause they don’t have the staff, the fi­nan­cial in­cen­tive or the pa­tience for the reg­u­la­tory bur­dens needed to pre­scribe it.

In its an­nounce­ment last week, the White House es­ti­mated the rule could in­crease treat­ment to “tens of thou­sands” of peo­ple with opi­oid-use dis­or­ders, but the level of un­met de­mand means the ef­fort would be un­likely to save many lives.

Ac­cord­ing to the Na­tional In­sti­tute on Drug Abuse, roughly 23 mil­lion peo­ple age 12 or older needed drug- or al­co­ho­labuse treat­ment in 2009. But only 2.6 mil­lion re­ceived it.

“It will make a dent,” Git­low said. “I’m not sure it’s a par­tic­u­larly con­vinc­ing dent.”

The opi­ate buprenor­phine treats ad­dic­tion to painkillers or heroin with less risk for abuse, or the phys­i­cal and psy­chologi- cal ef­fects of with­drawal.

Un­like methadone, which must be ad­min­is­tered daily in a clinic, buprenor­phine can be pre­scribed at a doc­tor’s of­fice and taken once a day at home.

Ap­proved for opi­oid-use disor­der treat­ment since 2002, buprenor­phine ac­cess has been lim­ited by fed­eral rules that re­quire in­ter­ested physi­cians to un­dergo an eight-hour train­ing sem­i­nar. Once au­tho­rized, a physi­cian can ini­tially treat up to 30 pa­tients and then, af­ter a year, ask to treat up to 100 pa­tients.

The pro­posed rule re­quires prac­ti­tion­ers to have an ac­tive waiver to treat up to 100 pa­tients for one year, and have board cer­ti­fi­ca­tion in ad­dic­tion medicine or ad­dic­tion psy­chi­a­try, or to prac­tice in a qual­i­fied set­ting.

Prac­ti­tion­ers who want the in­creased pa­tient limit must be able to of­fer pa­tients be­hav­ioral-health ser­vices such as ad­dic­tion-treat­ment coun­sel­ing. They must also use pa­tient data to

im­prove out­comes, and par­tic­i­pate in strate­gies to pre­vent pa­tients from il­le­gally giv­ing away their pre­scribed opi­ates. Cer­ti­fied physi­cians can be au­dited by the Drug En­force­ment Ad­min­is­tra­tion if their pre­scrip­tions are found to have been used il­le­gally. Clin­i­cians also would need to reestab­lish their el­i­gi­bil­ity ev­ery three years.

Git­low be­lieves these re­quire­ments would dis­cour­age some prac­ti­tion­ers from ex­pand­ing med­i­ca­tion-as­sisted treat­ment ser­vices.

“They may not em­brace it with quite the alacrity that we would all like to see,” he said.

The U.S. Sub­stance Abuse and Men­tal Health Ser­vices Ad­min­is­tra­tion re­ports there are more than 32,000 doc­tors cer­ti­fied to pre­scribe buprenor­phine in the U.S., with 68% lim­ited to pro­vid­ing the drug to no more than 30 pa­tients. Ap­prox­i­mately 10,000 doc­tors are cer­ti­fied to pre­scribe buprenor­phine to as many as 100 pa­tients. They rep­re­sent just over 1% of the coun­try’s more than 900,000 ac­tively prac­tic­ing physi­cians. A De­cem­ber 2015 Huff­in­g­ton Post anal­y­sis found that nearly half of the na­tion’s 3,100 coun­ties do not have a doc­tor cer­ti­fied to pre­scribe the drug.

Dr. Hi­lary Can­nery, Area 1 di­rec­tor for the Amer­i­can Academy of Ad­dic­tion Psy­chi­a­try, and as­sis­tant pro­fes­sor of psy­chi­a­try at Har­vard Med­i­cal School, said the pro­posed re­quire­ments should not de­ter physi­cians. She said the real prob­lem comes af­ter doc­tors get au­tho­riza­tion.

“A lot of physi­cians are very un­com­fort­able with the idea that they are go­ing to be as­sum­ing the risks for manag­ing these com­pli­cated pa­tients when they don’t have enough ther­a­pists or group coun­selors, or even ad­min­is­tra­tive staff to keep up with mon­i­tor­ing,” she said.

An­other hur­dle has been pay­ment for treat­ment, which Can­nery de­scribed as “no­to­ri­ously aw­ful” from pri­vate pay­ers, as well as from Medi­care and Med­i­caid. The drug of­ten needs prior au­tho­riza­tion.

The Af­ford­able Care Act re­quires health in­sur­ers to cover 10 essen­tial health ben­e­fits, in­clud­ing pre­scrip­tion drugs and sub­stance-use disor­der ser­vices, but it has been un­clear whether plans on the fed­eral mar­ket­place have to cover the full range of med­i­ca­tionas­sisted treat­ment.

Can­nery said progress is be­ing made to­ward im­prov­ing physi­cian pay­ment for med­i­ca­tion-as­sisted treat­ment, but more work is needed to cre­ate a struc­ture that will suf­fi­ciently sup­port pa­tient care for ad­dic­tion re­cov­ery.

Physi­cians, so­cial work­ers and con­sumer ad­vo­cacy groups have pres­sured the CMS to re­quire all health plans sold on the fed­eral ex­change to cover med­i­ca­tions used to treat peo­ple with opi­oid ad­dic­tions.

Along with rais­ing the pa­tient load cap, the White House also bumped fund­ing to fed­er­ally funded com­mu­nity health cen­ters by $100 mil­lion.

In its an­nounce­ment last week, the White House es­ti­mated the rule could in­crease treat­ment to “tens of thou­sands” of peo­ple with opi­oiduse dis­or­ders, but the level of un­met de­mand means the ef­fort would be un­likely to save many lives.

“A lot of physi­cians are very un­com­fort­able with the idea that they are go­ing to be as­sum­ing the risks for manag­ing these com­pli­cated pa­tients when they don’t have enough ther­a­pists or group coun­selors, or even ad­min­is­tra­tive staff to keep up with mon­i­tor­ing.”

DR. HI­LARY CON­NERY Area 1 di­rec­tor for the Amer­i­can Academy of Ad­dic­tion Psy­chi­a­try, and as­sis­tant pro­fes­sor of psy­chi­a­try at Har­vard Med­i­cal School

AP PHOTO

The tra­jec­tory of opi­oid deaths in the U.S. should be at the top of the fed­eral gov­ern­ment’s radar screen, Pres­i­dent Barack Obama said dur­ing a panel dis­cus­sion last week with moder­a­tor Dr. San­jay Gupta in At­lanta.

Source: Jour­nal of Sub­stance Abuse Treat­ment Source: Physi­cian and Pro­gram Data | SAMHSA

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