Access to Buprenorphine Will Expand; News About CARA

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Last week, the Department of Health and Human Services (HHS) announced it was raising the limit on the number of patients each doctor can treat for opioid use disorder with buprenorphine, from the present cap of 100 patients to 275 patients. However, each doctor must first meet criteria and complete an application procedure to be approved for this higher limit.

Initially, HHS wanted to increase the limit to 200 but for some reason ended up with 275. It’s still an arbitrary number, and opioid use disorder remains the only disease to have patient enrollment limits legislated for physicians.

HHS still wants physicians to meet extra requirements before they are approved to accept 275 patients, as I blogged about in my May 8, 2016 post:

  • Have professional coverage for after-hours emergencies.
  • Provide case management services
  • Use electronic medical records
  • Must use that practitioner’s state prescription monitoring program
  • Accept third-party insurance
  • Have a plan to address possible diversion of prescribed buprenorphine medication
  • Re-apply for permission to treat up to 275 patients every three years
  • Supply yearly reports about their practice and their buprenorphine patients

For some of the reasons I names in my May 8th blog, at this time I’m not planning to request permission to treat more than 100 patients.

This measure by HHS is a good and positive thing, and will help more desperate people get treatment. Just because I have a few objections to several HSS’s requirements doesn’t mean other doctors will feel the same way. I expect many physicians treating opioid use disorder will undergo the procedure to expand their patient limit.

 

Meanwhile, both the House of Representatives and the Senate passed the Comprehensive Addiction and Recovery Act (CARA) as of last week, and the bill is going before the President for his signature.

This bill, considered weak by some members of the House, contained only a fraction of the requested money to treat addiction. However, other advocates for addiction treatment say even a weak bill is better than none.

CARA’s content addresses the following:

Expand availability of naloxone to law enforcement and first responders, in order to quickly reverse opioid overdoses and prevent deaths. I think our own Project Lazarus helped get this ball rolling many years ago, and I’m so grateful my OTP has had support from them to give our patients naloxone kits!

Expand education and prevention efforts toward teens, parents, and aging people to prevent drug abuse and promote treatment and recovery.

Encourage states to improve their prescription monitoring systems. I hope some of that money will be directed to interoperability, meaning it will be easier to access a neighboring state’s prescription monitoring program. I also hope the Veteran’s administration will start reporting their data about prescribed controlled substances, too.

Prohibit the Department of Education from rejecting financial aid for people who have had past drug offences. I didn’t know people with drug offences on their record were denied governmental financial aid. If we want people to improve themselves and their life situations, why would we deny help for them? So this measure in CARA is great.

Expand resources to identify and treat incarcerated people with substance use disorders using evidence-based treatments.

Great idea, about forty years late.

Expand drug disposal sites to keep leftover meds out of the hands of children.

Just a question I’ve always had…Of all the tons of medication which have been collected at these disposal sites, has anyone ever studied how much controlled substances are collected?

Launch a “medication assisted treatment and intervention demonstration program.”

Not sure exactly what this will look like, but good luck with all of that.

I feel like I’ve beaten my head against the brick wall of prejudice and stigma against MAT in my community for four years. All I have is a headache…and resentment towards the medical community. I’d be very happy if someone else wants to take over for a while.

Launch a program to promote evidence-based treatment of opioid use disorder.

Well, yeah. it needs to happen. Actually it needed to happen about fifteen years ago, but whatever.

Director money towards law enforcement, to get people with substance use disorders help, rather than incarceration. CARA wants law enforcement to be able to work with addiction treatment services.

I indulged a private snicker at that last one. What a change from only a few years ago.

About six years ago, I was trying to educate people about medication-assisted treatment of opioid addiction. I thought I could help educate law enforcement personnel about addiction treatment, since they encounter it so much. I used the internet to find a journal for law enforcement.

I wrote to the editor, offering to write an educational article for their publication about opioid addiction treatment. My hopes weren’t especially high, but I wanted to give it a shot.

I was surprised when the journal’s editor took the time to call me in person. I was so excited!

Then the editor started talking to me like I was a naughty child. He asked what made me think it was appropriate to waste his time with such a query letter. He said I should have known better than to think any of his readers would be interested in the kind of thing I was offering to write, and he was calling to see what kind of person would be so unwise as to think otherwise.

I was stunned. I regret my reaction to him. I was so taken aback that I started apologizing to him, and said I was so sorry for bothering him and wasting his time.

In reality, he behaved like an asshole. If he didn’t want to waste time, he could have passed on the urge to call me to tell me how stupid he thought I was.

I wish I would have stuck up for myself in that conversation. I like to think I would handle it differently today.

Anyway, now, six years later, the government earmarked money to help law enforcement learn about opioid use disorder treatment.

While writing this article, I’ve come to realize I have bitterness towards people in law enforcement, medical fields, judicial, etc…when they denigrated my efforts to educate them about medication-assisted treatment for opioid use disorder.

I don’t want this bitterness. It’s too hard on me. It’s a weight that interferes with my enjoyment of life, and I’m going to release it.

The tide has begun to turn. We have legislation addressing the terrible opioid addiction problem we have, and money earmarked to help the problem. I want to be able to work with people who may have said bad things about medication-assisted treatment of opioid use disorders in the past. I want to work with those people without feeling resentment and without indulging in sarcasm.

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12 responses to this post.

  1. Posted by Alan Wartenberg MD on July 17, 2016 at 6:49 pm

    Jana, good luck dealing with your bitterness! I have about 40 years worth backed up in my “system” as well. Years spent pleading, begging, ranting, raving, arguing, cajoling and everything in between with my colleagues, with politicians, with regulators, with the general public. My colleagues often ask me why I am in this field, since my patients are “SO difficult.” My response is that on my list of difficult people, my patients are at or near the bottom, and that they (my colleagues) are a lot closer to the top.

    I have decided to take the view that ’tis an ill wind that blows no one good, and that the silver lining in the opioid epidemic cloud is a gift from God, and that to ignore it, or to squander the opportunity because it didn’t come 40 years ago, isn’t gonna help me one little bit. And I know that you know that too.

    I will accept this gift even if it is too little, too late and given for all the wrong reasons. Let us hope that the funding bills following CARA’s becoming law give it the wherewithal to do what needs to be done, or at least to get a damn good start.

    Thank you for all you do.

    Reply

    • Thank you Dr. Wartenberg. Those are wise words, and you put things into perspective. You have worked in this field for years – maybe decades – longer than me, so if anyone knows how to deal with the feelings from dealing with hostile entities, it is you.
      I agree – it’s not the patients that are difficult – they are usually a dream compared to politicians/colleagues/law enforcement.

      Reply

  2. Posted by John Mark Blowen on July 18, 2016 at 12:14 pm

    Jana Burson – What about the idea of expanding the provider base by including NPs and PAs ? Having learned about some of the
    Suboxone practices in this area, I feel confidant that many of my colleagues could do better.

    Reply

    • Yes I left that out – I believe CARA does allow extenders to prescribe buprenorphine for addiction. They already are, so might as well make it legal.

      Reply

  3. You Should call the guy back and ask him if he has changed his mind now that Law Enforcement has helped create a pandemic of herion addiction.

    I get angry and annoyed almost daily this ones the latest a nice “expose” on Bostons “Methadone Mile” awful reporting link below (full disclosure the OTP I attend runs one of the clinics at this location that they took over from the Boston Health Department a year or two ago)

    https://apps.bostonglobe.com/graphics/2016/07/methadone-mile/

    Reply

  4. I just want to make a note concerning the EHR requirement. It states that if you are already required to use an EHR, you must do so. My practice is very small and I have a waiver from CMS that does not require EHR use and allows for paper claim submission. People need to look at this closely as I think if you have a waiver, you will still qualify.

    Reply

    • Not to my reading. However, if you look at the comment/answer section, in one place it says that they will not say to what degree you have to use EHRs. For example, they are not using the “meaningful use” standard that’s in place for Medicare/Medicaid.

      Reply

  5. Posted by Lois L. on July 23, 2016 at 11:04 am

    I agree with LISA, the requirements for treating 275 patients state only that you must use electronic medical records only if you are already required to do so. The new rule also states that you only need provide access to case management services and behavioral health services, and are not required to provide these yourself. The ability to refer patients to these services appears to be adequate. You need to accept insurance, but there is nothing that says you are prohibited from seeing cash patients or required to take all insurances. All of the requirements for a qualified practice setting seem to be things that most practitioners are already doing or are consistent with good practice already (such as be registered to use your state prescription drug monitoring program, providing emergency coverage after hours and on weekends).

    In addition, in the comments section of the rule, HHS states that they expect most if not all of currently waivered physicians will qualify for the new 275 patient limit.

    I wrote SAMHSA and asked when the application for the increased waiver would be available, and was told it would be available on August 8 on the SAMHSA website (http://www.samhsa.gov/medication-assisted-treatment). I also asked if the provider could immediately start treating up to 275 patient as soon as the application was submitted (which is the case for the current waiver to treat 100 patients). However SAMHSA did not respond to this part of my question.

    Reply

    • From what I understand, you can with the understanding that if your application is not approved, you need to tell the patients over your limit and refer them elsewhere immediately…it’s probably better to wait….

      Reply

  6. I have to tell you that I love your blog page. In all honesty, I qualify as a “qualified practice setting” for the patient increase and it is a very easy process. The EHR requirement only applies if you already have an established EHR set up and the rest of the requirements are things that most people treating patients successfully have already been doing if following the MAT guidelines and really caring about their patients. If this is not the case, then don’t increase your limits….

    Reply

    • I don’t under stand the requirements completely…I did read that the requirement to have an EHR (electronic health record) applies but only if you have an EHR, and that doesn’t make sense to me. The only other thing I’m unwilling to do is bill insurance. I spend enough time as it is just getting all my patients’ prior authorizations completed. That’s getting more & more difficult. By the way, I do follow MAT guidelines and I do really care about my patients. But I don’t care so much for their insurance plans.

      Reply

      • Please don’t think I was referring to you about not increasing your limits. There clearly are people who should not increase their limits but you are one of the best clinicians out there!!! My comment was more a general statement for people who don’t take the time to properly assess their patients and follow MAT. You are wonderful and I read your posts over and over again. Thank you so much. I don’t know about the insurance requirement as I participate in many plans but half my patients are private pay because of the confidentiality issue and they don’t trust their insurance companies. I know a Dr. in town who is a Concierge Doc and he applied to increase… Maybe you could find a loophole. Your patients need you….and treatment saves lives!! This drug is a game changer for people. I don’t have to tell you that!!

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