SCOTTSDALE, ARIZ. – At a recent workshop on office buprenorphine prescribing, the first question addressed was: Is the 30-patient limit likely to be revised?
The urgency of the question is another sign that physicians who choose to become waiver-qualified to treat patients addicted to narcotics under the Drug Addiction Treatment Act of 2000 continue to find that the demand surpasses their ability to provide care.
Currently, about 5,000 physicians have the waiver to prescribe buprenorphine for addiction treatment, said Dr. Laura F. McNicholas, who led the workshop, which was held at the annual meeting of the American Academy of Addiction Psychiatry. It has been reported that fewer than half that number regularly prescribe, however.
Those who do prescribe tend to be swamped with patients. Many of the specialists who attended the workshop mentioned that they would like to be able to refer patients they have gotten stabilized to create more room on their rosters, but they have been unable to find other physicians to take those patients.
Last year, federal officials relaxed the limit set on the number of patients who could be treated from 30 patients at any one site to 30 patients per waiver-qualified physician. This has led many to question whether further relaxation is forthcoming.
Among those familiar with the machinations of the federal government, the sense is that Congress may be amenable to the idea of loosening the limits further because federal officials are satisfied with the way the program has been working.
But some limits will stay be in place, at least for the time being, said Dr. McNicholas, who recently chaired a panel that developed office buprenorphine guidelines for the Substance Abuse and Mental Health Services Administration.
The medical groups involved have not come to a consensus about the new limits they should seek from Congress, but discussions have begun, she added.
A recent assessment document on the buprenorphine prescribing program shows that even the Drug Enforcement Agency is satisfied with the program, said Dr. McNicholas, of the University of Pennsylvania Treatment Research Center, Philadelphia.
The document, which has been discussed but not yet finalized or published, says that, as expected, the program is reaching a different demographic of narcotics addicts than has traditionally been involved with methadone programs and other kinds of treatment. Those prescribed buprenorphine are more middle class and less likely to be addicted to heroin.
Figures in the report, which covers 3 years, indicate that about 60% of the patients treated through the program had never been in drug treatment before, and about 40% had been abusing diverted prescription medications, such as OxyContin, Dr. McNicholas said.
The report also says that while there has been diversion of buprenorphine, it does not appear to be a major problem. In fact, it notes that many of the cases have involved patients giving the medication to friends, who then find it so efficacious that they seek out treatment for themselves.
Another topic of discussion during the workshop involved the side effects that clinicians were seeing that were not particularly noted in the early trials of buprenorphine.
Several of those who attended the workshop said that some of their patients have headaches when they start the medication and some complain of feeling fatigued.
Dr. McNicholas said experience is suggesting that 20% of patients experience head-aches when they first go on buprenorphine, but that the condition always resolves in a few days.
Regarding the fatigue issue, Dr. McNicholas said she was skeptical of those complaints because, kinetically, the drug should not have that effect. However, when pressed by several of those who said that they did have fatigued patients, she allowed: “I am not saying it is not real, but I certainly haven't seen it–and we have no data.
“I hear things, frankly, that we did not see during the studies,” one of which was occurrence of headaches, she added.
There continue to be no worrisome reports of drug-drug interactions with buprenorphine. Such interactions were expected because it is given by sublingual administration; this is done so that large amounts do not assault the liver, but it means that most of the medication goes to the brain first.