PHILADELPHIA – Only about half of the physicians licensed to prescribe buprenorphine – an opioid-based medication to treat addiction – actually prescribe it to patients, a national study from the Pew Charitable Trust has found.
Buprenorphine has been marketed as more accessible than methadone, another opioid-based addiction medicine that long has been dispensed only through federally licensed treatment centers. Bupe, as many patients and practitioners call it, can be prescribed from physicians' offices and taken at home, but significant federal restrictions still surround its prescription and use.
Physicians who treat substance use in Philadelphia said the study shows the need for more doctors to be licensed to prescribe buprenorphine – or to remove the licensing requirement altogether. After all, many argue, no such special license is needed to prescribe the painkillers that are at the root of so many addictions.
Doctors must take a special course in order to prescribe buprenorphine and, once they pass, may take on no more than 30 patients with opioid use disorder. (Later, they can ask to take on a larger patient load, and some doctors are permitted to prescribe buprenorphine to up to 275 patients.)
As of 2018, only about 5% of physicians had a license to prescribe buprenorphine – despite increasing demand for the drug and an overdose crisis that killed 70,000 people in the United States last year alone.
"(Bupe) can be prescribed for pain without any of these regulatory requirements. When prescribing it for opioid use disorder, it's layered with all these barriers. There's a stigma around the medication," said Beth Connolly, the project director of Pew's substance use prevention and treatment initiative. "It was really important to study what some of the barriers are, and whether people are actually prescribing it."
The study looked at the monthly buprenorphine patient volume for physicians licensed to prescribe the drug between April 2017 and January 2019. Just over 50% wrote at least one prescription during that time period. And most of the physicians who did regularly prescribe it didn't hit their "patient cap," in some cases prescribing to just a handful of patients.
The problem isn't necessarily that individual doctors aren't prescribing to as many patients as possible – it's that so few doctors can prescribe buprenorphine at all, said Jeanmarie Perrone, the director of the Division of Medical Toxicology and Addiction Medicine Initiatives in the University of Pennsylvania's Department of Emergency Medicine.
"I think what we need is more doctors in general – to let anyone prescribe," said Perrone, who has spearheaded an initiative to get more emergency physicians licensed to prescribe the medicine.
Treating addiction can be complex, she said, and an individual doctor with 275 buprenorphine patients on their roster might have trouble "providing the support and attention to patients at this level," Perrone said.
"I wouldn't challenge someone too much if they said, 'I know my cap's at 30, but I want to provide the best care for these 27 people I'm caring for,' " said David O'Gurek, an associate professor of family medicine at Temple University Health System.
Still, O'Gurek said, the stigma of addiction treatment keeps other doctors from considering getting licensed.
"You hear from doctors, 'My practice is going to become overrun with people with opioid use disorder,' " he said. "But the reality is that people with opioid use disorder are likely already currently in your practice. Whenever I'm giving a training, I talk about how, as a family physician, doing this type of care is probably the easiest thing I do all week. There's complications and stress, but those exist in a regular primary care day."
During the COVID-19 pandemic, some of the federal restrictions around buprenorphine and methadone have been relaxed in the name of social distancing. Buprenorphine can be prescribed via telemedicine now – previously, federal law required an in-person appointment. And patients can obtain take-home doses of methadone – previously a privilege for just a few.
Connolly said that Pew's researchers have anecdotal evidence that more people have been accessing buprenorphine treatment in general, and added that she hopes the relaxed requirements around prescribing can be sustained after the pandemic passes.
Silvana Mazzella, the associate executive director of Prevention Point – the Philadelphia public health organization for people with addiction – said staff had been terrified they would lose patients in the medication-assisted treatment programs during the pandemic. Many of Prevention Point's clientele are homeless and don't have phones to access telehealth options.
"But we actually went up in adherence," Mazzella said. "With limited treatment and almost nothing being open during the first two months of COVID-19, people were clinging to whatever resources they had."
But the pandemic has complicated addiction treatment in other realms. In the three Penn emergency departments where Perrone has pushed for more buprenorphine prescriptions, the number of patients seeking help for withdrawal plummeted during the pandemic, likely for fear of contracting COVID. Withdrawal is a key opportunity for doctors in the ER to encourage someone into treatment.
About 20 patients a month came to the ER needing buprenorphine before the pandemic, Perrone said. That's dropped to about six a month, she said, and many of the patients who have made it to her ERs say they relapsed during the pandemic.
"I see a lot of people whose last (buprenorphine) prescription was in March," she said. "And you ask them, and they've all fallen off because of logistics, access (to healthcare), fear, money, housing, everything."
Physicians said they hope the lessons they are learning about addiction treatment during the pandemic spur permanent changes.
"We need to address the reasons why people are (licensed to prescribe buprenorphine) and aren't using it. We need to make sure we're building the type of treatment system patients need and want, one they design on their own," O'Gurek said. "I think health systems right now are so taxed and still sort of in pandemic mode. But it really is a critical opportunity to really evaluate the way we were doing things before, and how we do things onward."
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