10/11/2010, Barriers Remain for Primary Care Treatment of Addicts


It’s a fairly new approach to fighting addiction — not just because it has a novel mechanism of action, but because it can be prescribed by a primary care doctor.

Now that primary care doctors can’t prescribe the opioids that work, they get to prescribe the ones that don’t.

“We have a raging epidemic of addiction, and the most effective treatment is buprenorphine,” said Andrew Kolodny, MD, a psychiatrist who specializes in addiction medicine at Maimonides Medical Center in Brooklyn, N.Y. “How long will [patients] have to suffer before they have better access to this treatment?”

A raging epidemic of addiction?  Seriously?  And why aren’t you concerned about the suffering of chronic pain patients, Mr. Kolodny?  Only worried about drug addicts?

It’s the only partial agonist approved for opioid addiction, but it’s comparable to varenicline (Chantix), a partial agonist for smoking cessation.

Have rarely heard good things about Chantix…

…data from 2009 show that only about 19,000 U.S. physicians are certified to prescribe buprenorphine, and about 640,000 patients are currently receiving treatment.

Reuter says that was to ensure the safe distribution of the drug. The Drug Addiction Treatment Act (DATA) 2000 marked the first time addiction patients could be treated in a physician’s office. Concerns arose that this would make it easier for substances to be diverted.

Why would being treated at a doctor’s office allow for easier diversion?

Others say the “methadone lobby” had a hand in crafting the regulation. Addiction experts say that buprenorphine is an economic threat to the industry of drug makers and clinics. Mark W. Parrino, president of the American Association for the Treatment of Opioid Disorders (AATOD), which was involved in discussions in Washington on the regulation, called speculations about the methadone lobby an “urban legend.”

There are also concerns about random Drug Enforcement Agency checks that some physicians feel may intimidate guests in the waiting room…

The DEA doesn’t have to be present to intimidate or threaten…

It’s also not covered by all insurers, potentially leaving patients with an out-of-pocket bill in the range of about $350 to $400 per month…

SAMHSA estimates that between two and six million patients in the U.S. abuse opioids, and there’s at least an equivalent number of heroin addicts…

Let’s see, between 2 and 6 million patients… yeah, I’d say you could define that as an “estimate.” And instead of lumping patients who “abuse” opioids with those who suffer from addiction and use illegal heroin, why not make the comparison between, say, white people and black people? No, that’s silly, everyone knows that white people use both opioids and heroin more than black people. How about between people who have access to opioids and those who don’t?

Like many rural areas, the prescription painkiller epidemic is rampant, but the region’s only methadone clinic is in Flagstaff and there is just one physician certified to prescribe buprenorphine. The person is Sue Sisley, MD, and her neighborhood is several hundred square miles of Arizona territory. But technology allows Sisley to make house calls even when the house is more than 150 miles away from her desk. She treats patients via a telemedicine program at the University of Arizona…

I believe Dr. Sisley is now in Colorado working on medical cannabis research for PTSD.

Bondina Stone is a registered nurse in the rural Appalachian town of Mineral Wells, W.Va., which she says is mired in the OxyContin epidemic. Stone’s own struggle with addiction began after a 1993 accident that left her in severe pain. She was on and off painkillers for years, sometimes after unsuccessful attempts at treatment with methadone. Finally, in 2008, she was able to get a prescription for buprenorphine.Her take on buprenorphine: “It makes you feel normal,” unlike being on methadone, where “you still get a little high.”

When I took methadone for pain, I never got “high.”

Alfieri said that some patients do complain about not being able to come off even a very low dose. The company is also investigating a six-month implantable version of the drug…

And the drug is not without risks. Even in France where the drug is credited with reducing both drug overdoses and injection drug use, when buprenorphine was introduced there was a simultaneous uptick in opioid-related deaths due to an unforeseen consequence of combining crushed, injected buprenorphine with benzodiazepines like diazepam (Valium) or excessive alcohol intake. 

Since diversion was an anticipated concern, addiction specialists in the U.S. have favored Suboxone, a version of buprenorphine that contains naloxone (Narcan), an opioid antagonist, in a 4:1 ratio. “If you crush it, the naloxone kicks in and sends you into horrible withdrawal, so you don’t want to do it again,” Levounis said.

Sounds like brain torture…

Reuter said there was an increase in buprenorphine diversion in 2006 that has since leveled off. And the diversion rate with buprenorphine remains low compared with that of opioid analgesics. Suboxone has also been diverted in a less expected way. Prescription painkiller addicts will sometimes attempt to acquire it themselves, in order to kick their habit. The treatment, however, requires that the patient be in withdrawal before starting it.

A treatment for addiction that you can’t use until you’re in hell… brilliant.

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