by Terry DeMio , [email protected] –
More doctors than ever in the United States are armed with a medication scientifically proven to fight the heroin and opioid epidemic. Yet many don’t prescribe it to as many patients as they are authorized to help.
Research published in the American Journal of Public Health in June 2015 found that 43 percent of potential patients who could have received the drug were not offered it.
And while more doctors are asking to prescribe the drug in 2017, experts worry that the gap – the one between those who qualify for the drug and those who actually get it – is not being addressed.
“Discrimination is real and does still happen,” said Dr. Kim Johnson, director of the Center of Substance Abuse Treatment, an arm of the federal Substance Abuse and Mental Health Services Administration. The agency has been at the forefront of providing doctors with buprenorphine-prescribing training and the public with lists of doctors who can do so.
Buprenorphine reduces opiate cravings and stabilizes patients with heroin- or opioid-use disorder. It can prevent relapse into use, and overdoses.The medication, known to many by brand name Suboxone, fills the opioid receptors in the brain. But it is a synthetic opiate, which makes some doctors hesitant to prescribe it.
One of Northern Kentucky’s leading certified addiction specialists, Dr. Mina “Mike” Kalfas, is open about the fact that he was biased as a young doctor and didn’t want to provide addiction care. Once he did, Kalfas said, “I fell in love with it.”
Kalfas lists the reasons other doctors don’t prescribe buprenorphine:
- They have a poor understanding of addiction as a disease.
- They have “a bias that blames the patient.” Linda Richter, director of policy research and analysis for the National Center on Addiction and Substance Abuse agrees: “A lot of physicians are reluctant to have people with addiction disorders come to their offices.
- The patients are frustrating. “They are manipulative, they are expert liars, they often do not want what is best for them,” Kalfas said. Johnson agrees. “What we’re finding is that we are asking physicians to care for more and more complex patients,” she said. “People with opioid use disorder can be those complex patients.”
- They are fearful. “The actual prescribing of medication flags you” for Drug Enforcement Administration audits. Doctors are under scrutiny as soon as they take on the job.
- Finally, they face the disapproval of peers. “I’ve heard colleagues refer to Kalfas’s druggies,” he said.
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There are other, practical reasons that doctors avoid medication assisted treatment, said Dr. Shawn Ryan, a board-certified emergency physician and addiction specialist.
“They aren’t set up to do it,” Ryan said, adding that primary care physicians aren’t educated or prepared to deal with serious cases.
His BrightView Health outpatient opioid addiction treatment offices in Colerain Township and Norwood have every service the patients need on site, including a psychiatrist. The staff is trained to react more like an emergency department than a regular doctor’s office, he said. Together, the staff treats about 500 patients with buprenorphine.
The lack of integrated care can be a problem, but it’s one that must be overcome, said Lindsey Vuolo, associate director of Health Law and Policy at the National Center on Addiction and Substance Abuse. Evidence shows that medication assisted treatment is best for opioid- and heroin-use disorder.
“Any solution should be tailored and targeted to address the specific barrier,” Vuolo said. “A solution to address this barrier would be to link PCPs (primary care physicians) with programs that provide these services so they can refer their patients.”
“Get the specialists to treat patients and get them stabilized, hand off to primary care physicians, then go back to the specialists as needed,” Johnson said.
Nationwide, only about 11 percent of people who need addiction disease treatment are getting it. Ryan says that figure is high because many with opioid and heroin addiction who are being treated aren’t getting the standard care, which is medication-assisted treatment. “Do we need more doctors? Absolutely,” Ryan said.
Even if primary care physicians would treat their patients who are already receiving general care, it would help. “You’re probably seeing people in your facility or practice who have an opioid use disorder and you don’t know it,” Johnson said.
Rules, regulations on prescribing drug eased
It’s becoming simpler to get the waiver to prescribe, and there’s free help for doctors who are concerned about prescribing buprenorphine.
Dr. Adam Bisaga, professor of psychiatry at the Columbia University Medical Center, is among addiction experts who take part in the Physician Clinical Support System for buprenorphine training. The mentoring program helps doctors incorporate medication use into their practice and provides expertise and clinical education. It’s done by phone, email, or in some cases, in person.
Bisaga said the service has had 22 applications for help from Ohio and nine from Kentucky.
As of last week, 36,889 physicians across the United States had the waiver to prescribe buprenorphine. Because of federal limits on patient load, most who can prescribe it can only do so for up to 30 patients. More experienced doctors, or only 8 percent of those with waivers, can treat up to 275 patients. Buprenorphine is the only medication that has patient limits. In 2016, the federal government increased the limit for experienced prescribers to 275 patients, but addiction specialists wonder why there are any at all.
Every year, more doctors get certified to provide buprenorphine. Ohio made a big jump in 2016, with 275 new physicians getting the waiver, up from 157 new physicians doing so in 2015, Johnson noted. Kentucky’s year-over-year remained steady at about 100 new prescribers, she said.
“We’re getting places,” said Ryan.
Kalfas, too, sees progress regardless of doctor holdups:
“In spite of all this, there are still a few of us to stand up and say, ‘Sign me up!”
Find a doctor in your state and county who is certified to prescribe buprenorphine at SAMHSA.org or visit SAMHSA.gov and search for buprenorphine treatment physician locator.
- Lower the potential for misuse of opioids or heroin.
- Diminish the effects of physical dependency to opioids, such as withdrawal symptoms and cravings.
- Increase safety in cases of overdose. – Source: Substance Abuse Mental Health Administration
