Addiction Expert: Care Needed in Implementing New Buprenorphine Prescribing Rules

In January, new government regulations took effect that allow greater take-home privileges for buprenorphine patients who are treated in clinic-based Opioid Treatment Programs (OTPs). While this change will allow more patients to have increased flexibility as they progress in their recovery, providers must be careful in deciding who to give the medication to, in order to avoid diversion, says a New York addiction specialist.

“Prescribers and the rest of the health care team need to have a dual focus on both doing everything they can to help the patient, and also trying to keep buprenorphine prescribing safe by limiting misuse, abuse and diversion that may come about by their prescribing,” says Dr. Edwin A. Salsitz, MD, Medical Director, Office-Based Opioid Therapy at Beth Israel Medical Center.

The changes in regulations, made by the Substance Abuse and Mental Health Services Administration (SAMHSA), do not apply to methadone treatment. Previously, patients could not receive a one-week take-home supply of buprenorphine or methadone from an OTP until they were stable in treatment for nine months. Under the new rule, this time requirement for patients receiving buprenorphine products no longer applies. If an OTP physician program physician determines that a patient is suitable, the program can dispense a one-week supply of medication, or longer, to a newly admitted patient.

SAMHSA made the changes based on several factors, including differences between methadone and buprenorphine in abuse potential and actual abuse, death rates, and the fact that methadone is subject to tighter federal controls than buprenorphine. “Buprenorphine abuse has been increasing, but SAMHSA believes that the controls and oversight in place in the OTP, as well as enhanced monitoring will mitigate abuse concerns,” the agency stated in a letter to treatment providers.

Buprenorphine also can be prescribed by certified physicians in an office-based setting, known as office-based opioid treatment (OBOT). Office-based treatment is a popular choice among patients who wish to avoid daily visits to a treatment clinic, Dr. Salsitz notes. However, he adds, not all patients are initially suitable candidates for office-based treatment. “The main benefit of someone going to an opioid treatment program and being dispensed buprenorphine is the security and structure that OTP provides,” he says. “It is virtually impossible for an OBOT to provide the same oversight, structure and security for both the patient and the medication, as is provided by clinic-based treatment. One possible paradigm is to begin buprenorphine treatment in an OTP if enhanced oversight and structure are needed, and then when the patient has stabilized, the patient can be referred to an office-based treatment program.”

Choosing whether a patient addicted to opioids should be treated with buprenorphine or methadone, and whether they should be treated in a clinic or in a physician’s office, are complicated issues, Dr. Salsitz observes. “These issues currently have no clear answers, but they need to be researched and evaluated,” he says.

In stressing the need for strict oversight of buprenorphine prescribing, Dr. Salsitz pointed to a recent SAMHSA report that found hospital emergency department visits linked to buprenorphine increased substantially – from 3,161 visits in 2005 to 30,135 visits in 2010, with 52 percent involving non-medical use. He notes, “If a doctor gives a new patient 30 days of buprenorphine without any real followup, some of that medication may end up on the street.”

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    John joer

    June 6, 2015 at 12:49 AM

    I have been on the same meds for around 5 years now all of at a subuxone doc wants to cut me off of the program if I don’t get off my aderal and Xanax it was fine for 5 years now it’s not I personally think there’s a better chance of me relapsing bc the adderal keeps me level headed and busy then the Xanax never lets me get emotionally stable

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    Doug

    March 21, 2013 at 10:26 AM

    “Buprenorphine abuse has been increasing…hospital emergency department visits linked to buprenorphine increased substantially” with more than half “non-medical” so SAMHSA makes it easier to get, divert and abuse. Brilliant! Pot is still illegal, and drugs like opioids, alcohol and tobacco are still readily available thanks to their lobbyists. And people make fun of our government for some strange reason.

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    Giselle Ontra

    March 17, 2013 at 3:06 PM

    Thank you for posting updated and such important information.. We, as parents devour this information

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    Jose roberto Colindres Lopez j

    March 16, 2013 at 2:50 AM

    Subutex save my life now I help opiates addicts the real truth is if you’re ready or not if not nothing or nobody will help.
    Thank you.

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    Doc Barry

    March 15, 2013 at 11:54 AM

    While Dr. Salsitz is probably the person that I respect most in treating patients with opiate/opioid disorders, I have to disagree with his statement. Currently, I am a Clicial Social Worker, and I treat more than 100 patients that are prescribed suboxone. The key, where I will agree with Dr. Salsitz, is the initial assesment. Some folks are not ready to be given even a week’s worth of medication; there addiction has too strong of a hold on them, and they lack the ability without more structure, to make the necessary changes from addiction to sobriety. A patient that is sober, that is prescribed suboxone or methadone, and no other mood altering drugs, is as sober as the alcoholic that is prescribed anti-depressants. Unfortunately, NA has chosen to stigmatize these folks out of some crazy jealousy, without really understanding the fundamentals of 12 Step Programs.
    I did stray from the point. Our office incorporates MAT in a family care setting. Currently, I work with three physicians that prescribe suboxone. Currently, if there any physicians that read this response, please contact me, because we are in dire straights for prescribers in Central New York. I have a team of well trained clinicians that see patients, however, we need physicians to obtain their x-number. Currently, we have seen many patients that within days, have their lives back; we also see patients that need treatment, some inpatients, some outpatient. My belief, is that there has to be trust, and in general, clinics continue to stigmatize. The worst thing possible for a person struggling with dependency.

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