Buprenorphine at Opioid Treatment Programs

addicthekp

In this column and columns to follow, I’d like to describe in broad terms how we’ve implemented buprenorphine into the opioid treatment programs where I work, the benefits we’ve seen, and also some of the unexpected challenges we’ve had.

I’m fortunate to be the medical director at two opioid treatment programs that offer buprenorphine (active ingredient in the name brand products Suboxone & Subutex) in addition to methadone. I consider this to be the state of the art for opioid treatment programs, formerly called methadone clinics. Now, we can offer buprenorphine first-line, and save methadone for patients who don’t respond well to buprenorphine, and who need a stronger medication.

Don’t get me wrong – I prescribe methadone, and know that it’s a potentially life-saving medication when used appropriately. We have decades of evidence to show that it reduces death and disability in opioid addicts, reduces crime, increases employment, and reduces the risk of HIV. But addiction medicine, like in all other fields of medicine, needs to change with the science. We shouldn’t remain stuck in old ways of thinking. Buprenorphine is a partial opioid, with a ceiling effect, and for that reason is safer than methadone, which is a full opioid. There’s nothing wrong with methadone – but buprenorphine may be a better medication for many patients.

At one of my clinics, approximately half of our three hundred and sixty or so patients dose daily with buprenorphine, and the other half with methadone. I didn’t create this program. Another doctor created the program, and then after a few years sold it to a large mental health care company. I was lucky enough to get hired during the transition, and I’ve had a great time since starting to work there. At my other program, we have a significant minority of our patients dosing on buprenorphine. I’ve been with this program since its inception, and have helped develop techniques for use of buprenorphine from the start.

First of all, a distinction must be made between buprenorphine when prescribed in an office-based program, and buprenorphine prescribed and dispensed in an opioid treatment program. These two settings have different regulations.

An office-based program, frequently termed an OBOT, exists when a doctor who possesses the special “X” DEA number sees patient in an office setting, and writes prescriptions for buprenorphine for patients. The patient pays his doctor for each visit, or his insurance company pays. The patient takes the prescriptions to his pharmacy, and pays with whatever means he has – insurance or self-pay.

A doctor in this office-based setting must take a special course and apply for the special “X” DEA number. He can only have up to thirty patients the first year. After that, the doctor can petition to have up to one-hundred patients for whom he’s prescribing at any one time. In this state, the doctor also has to register with the state’s department of health and human services. That doctor’s office is subject to inspection by the DEA at any time (see my positive experience with this in my blog of December 16th, 2012).
The doctor has to have the ability to refer for counseling, though in our state it’s necessary to have some sort of written agreement with the person or facility who will provide the counseling.

Beyond these recommendations, the physician has wide latitude to alter treatment to fit the patient’s needs. This flexibility is the big advantage that office-based programs have over opioid treatment programs. Some patients may need to be seen every week. Some stable patients, in recovery for years, may need to be seen once every two months. The physician has the freedom to decide frequency of visits, of drug screens, and also the duration of treatment, though ideally with the collaboration and input of the patient.

Doctors working in opioid treatment programs have different regulations. Opioid treatment programs are heavily regulated by state and federal laws, and are inspected by the DEA, the state’s department of health and human services, and each state’s methadone authority, which now also encompasses buprenorphine, when prescribed in OTPs. Buprenorphine patients must follow all of the same regulations as methadone patients. There are a prescribed number of urine drug screens that must be obtained, and half of these must be observed. Bottle recalls to check for medication diversion must be done just like with methadone patients. The federal government recently dropped the requirement of time in treatment criteria for take homes for patients on buprenorphine, but that won’t apply in states with stricter state regulations, like mine. (See my blog of 1/20/13).

However, at an opioid treatment program, the doctor isn’t required to have an “X” number to prescribe buprenorphine rather than methadone. And there are no limits on the number of patients dosing with buprenorphine, so long as the buprenorphine is dispensed under the OTP’s DEA number and not the physician’s “X” number. This is how I’m able to prescribe buprenorphine at OTPs, while still maintaining my office based practice, so long as the latter number stays less than one hundred.

At the OTP, counseling requirements are already built into the system, and don’t differ for patients on buprenorphine compared to those on methadone.

This is confusing stuff, not only for the patients but also for clinic staff and even doctors. I’ve seen patients who were in an office-based program become confused and resentful about the different requirements when they had to switch to an opioid treatment program for buprenorphine. Hopefully I’ve helped illuminate why the regulations are different even though the medication is the same.

In the next blog I’ll talk about some of the specific challenges of using buprenorphine in the OTP setting.

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5 responses to this post.

  1. Posted by Travis on February 3, 2013 at 5:17 pm

    Just out of curiousity how do you personally deal with counseling referrals within your office-based buprenorphine practice? Do you employ an addiction counselor or professional counselor of some sort within the same office or do you refer out to a seperate facility?

    Reply

    • Yes, I have a counselor who has his master’s degree in addiction counseling, and he’s also an LPC. But if a new patient already has a therapist she likes, I”m OK with that, so long as there’s a release so I can speak to that counselor to make sure addiction issues are being addressed. I’m even open to only 12-step meetings, so long as I can be reasonably sure they are going. If they say they can’t afford a private counselor, but agree to 12-step meetings, which are the best deal in town, I’m OK with that. Unless they never really go to meetings. then I’m unhappy and we have a problem.

      Reply

  2. Posted by Lrm40 on February 4, 2013 at 3:18 pm

    Today is my 35th day off suboxone! I
    Am back to feeling 100%. Thank you God. Thank you self!!

    Reply

  3. Dr. Jana, thank you so much for explaining in detail the special requirements for the use of bupronorphine in opiod addiction treatment. I have been in a program with a professional counselor for almost 2 years, and highly recommend bupronophine as a means of treatment. One of the hardest things I’ve found concerning my treatment is getting my family to understand the effects of Subutex(bupronorphine), as they feel I am only trading one drug for another when they see bupronorphine is a partial opioid. I can understand their concern, but am steady trying to explain the ceiling effect and lack of euphoria with the use of bupronorphine. I’m sure this column and the future ones you produce will help them understand the restrictions and value of bupronorphine. I especially like the “state of the art” quote, as I feel bupronorhine is certainly state of the art, and for me personally has been a life saver. I began my treatment using a daily dosage of 2 8mg subutex per day and am currently down to 1/2 an 8 mg pill per day. I do want to give caution to reducing the dosage over an extended period of time. To all you fellow addicts, take it slow, don’t try to cut back too fast, be patient. I tried going from 2 pills per day to 1 and found out the hard way that I should not have been so progressive, meaning reduce the dosage from 2 pills to 1 1/2 then 1 then 3/4 then 1/2 over several months. Bupronorphine is a powerful drug and caution should be taken in getting your body to become independent from it all together. Discuss with your treatment professional how you react, how much you are “jonesings” as you strive to become totally drug free. Trust me, it can change your life. Bupronorphine is a wonder drug. Thanks for listening.

    Reply

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