Among the White House's new tools unveiled this week to combat the opioid abuse epidemic is a proposed rule to double the patient load 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 or the financial incentive to prescribe it.
The White House estimates the rule could increase treatment to “tens of thousands” of people with opioid use disorders, but the level of unmet demand means the effort is unlikely to make a big enough difference in saving lives.
According to the National Institute on Drug Abuse, roughly 23 million persons 12 or older needed drug or alcohol abuse treatment in 2009. But only 2.6 million received it.
“It will make a dent,” said Dr. Stuart Gitlow, immediate past president of the American Society of Addiction Medicine's board of directors. “I'm not sure it's a particularly convincing dent.”
The opiate buprenorphine is used to treat addiction to painkillers or heroin. Unlike those drugs, buprenorphine does not carry the same risks for abuse and does not carry the physical and psychological effects of withdrawal. Unlike methadone, buprenorphine can be taken once a day at home.
Approved for opioid use disorder treatment since 2002, buprenorphine's access has been limited by federal rules that require interested physicians to undergo specialized training. Once a physician is authorized to prescribe an opiate-based treatment such as buprenorphine, he can initially treat up to 30 patients at one time and then, after one year, file a request to treat up to 100 patients.
The new rule requires practitioners to have an active waiver to treat up to 100 patients for one year and have subspecialty board certification in addiction medicine or addiction psychiatry or practice in a qualified practice setting.
Practitioners seeking the higher patient limit would need to adhere to a number of requirements. Among would be offering patients behavioral health services such as addiction treatment counselors. They would also use patient data to improve outcomes and participate in strategies to prevent patients from giving their prescribed opiates to another person illegally. Practitioners also would need to reaffirm their eligibility every three years.
Those additional responsibilities will likely be viewed as burdens, said Gitlow, who believes that will deter physicians. “They may not embrace it quite with the alacrity that we would all like to see.“
The U.S. Substance Abuse and Mental Health Services Administration reports there are just more than 32,000 doctors certified to prescribe buprenorphine in the U.S., with 68% limited to providing the drug to as many as 30 patients.
Approximately 10,000 doctors are certified to prescribe buprenorphine to as many as 100 patients, which represent roughly just over 1% of the country's more than 900,000 actively practicing physicians.
Dr. Hilary Connery, Area 1 director for the American Academy of Addiction Psychiatry and assistant professor of psychiatry at Harvard Medical School, said the new requirements should not deter physicians. She said the real problem lies 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 major barrier has been payment for the treatment, which Connery described as being “notoriously awful” from private payers as well as from Medicare and Medicaid.
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 had to cover the full range of medication-assisted treatment.
Connery said progress is being made toward trying to improve physician payment for medication-assisted treatment, but more work is needed to create the structure that will sufficiently support patient care for addiction.
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.