Never mind….

You know that blog I posted a few weeks ago, about DHHS’s decision to allow any physician with a DEA license to prescribe buprenorphine products for their patients with opioid use disorder? That idea has been nixed. SAMHSA said HHS’s decision to announce the change of regulations to have been “premature.”

I have no idea what political machinations were behind all of this, but Medscape’s webpage said loosening the restrictions was an idea put forward by Trump’s administration, and Biden’s administration cancelled that plan.

Many addiction medicine specialists were wary about the idea of loosening restrictions, fearful of the consequences if any physician could prescribe buprenorphine without the mandatory training course. That eight-hour course teaches providers about opioid use disorder in general and specifically about how to prescribe buprenorphine products from an office-based practice to treat that disorder. They say prescribers need this education, since for decades it was illegal to treat opioid use disorder from an office setting. Consequently, most physicians don’t know much about treating addiction, and may mistakenly think it’s the same thing as treating pain.

On the other hand, eliminating the need to take this course could encourage more doctors to prescribe buprenorphine products to treat opioid use disorders, thus expanding access to treatment.

I’m not sure what I think.

 On the one hand, I’ve seen providers with no training or “X” number prescribing all sorts of buprenorphine products for years, and not always with the diligence I would hope for.

For example, several months ago I reviewed a new patient’s data from the North Carolina prescription monitoring program. I saw the local pain clinic had been prescribing an extended- release full opioid agonist, along with a short-acting full agonist for breakthrough pain for many months. Then I saw the Butrans patch (contains buprenorphine) was added to this regime of medication.

I asked the patient what happened when they started the Butrans patch.

“Oh I found out I was allergic to it. It made me very sick. I felt like I was back in withdrawal. I can’t take that medication.”

Of course, that was no allergic reaction. That was precipitated withdrawal, predictable to providers familiar to the pharmacology of buprenorphine. But now this patient is convinced that buprenorphine in any form will make her sick under any circumstance. She was started on methadone and has done very well, but it is a shame she had to be put through that nightmare.

However, another prescriber, this one who took the eight-hour course and who has a DEA “X” number, starts all patients at a dose of buprenorphine/naloxone 32/8mg per day (four of the 8/2mg tablets) and tapers down over a period of several months until the patient is off the medication completely. Apparently this prescriber wasn’t paying attention to instructions given at the 8-hour training course about how to do induction. Or how to do maintenance. Or that most patients need much longer than several months on the medication to remain in recovery, and few need any higher dose than 16 to 24mg per day.

Then there’s another prescriber in town, also with her DEA “X” number, who accepts methadone patients from our opioid treatment program and starts them on buprenorphine without asking for any data from us. We only find out about the patient’s medical misadventures when their counselor calls them, to find out why they’ve missed days of treatment with us. The patient says he told the prescriber what dose of methadone he was currently on, and but prescriber asked the patient to miss one or two days of methadone before she started a sublingual buprenorphine product.

If they patient was on a dose of 40mg or less for at least a week, everything will go well. But if the patient’s been dosing at 110mg per day, per example, and missed a few days…things usually don’t go well. The patient ends up in precipitated withdrawal, which is completely predictable. If we are lucky, we can get them back into treatment right away.

At our opioid treatment program, we switch patients all of the time, though much more slowly. My usual “recipe” for switching involves tapering by 5mg per week, down to 40mg, where they dose for at least a week. Then the patient misses two days and sees me on the third day. If they are in sufficient withdrawal, with a COWS greater than 12, I feel safe starting them on buprenorphine. I usually end up dosing them with between 4 to 8mg on that first day.

Anyway, my point is that most of these prescribers, who took the eight- hour course, don’t necessarily do things as I would hope they learned in the course. But perhaps it would be worse if buprenorphine prescribers took no course.

My opinion about this issue rockets from one side to the other faster than a tennis ball at Wimbledon.

I can’t decide what I think. I read opinions from leaders in the field that say untrained prescribers could lead to disasters, and I know they are correct. Then I read from other leaders in the field that increasing access will save lives and I know that’s right, too.

I have no conclusion for this blog post. I’m just acknowledging uncertainty.

16 responses to this post.

  1. Posted by Lee Dilworth on February 7, 2021 at 3:31 pm

    I always enjoy reading your blog. Thank you for so thoughtfully acknowledging this tension.

    Reply

  2. Posted by Arthur McMigraine on February 7, 2021 at 5:06 pm

    Dr. Bryson: I cannot overstate how refreshing it is to hear an MD say those 3 little words: ‘I don’t know’ I wish you could bottle your humility & share it with your colleagues. I do know not all doctors develop a god complex, but currently I and some members of my family are dealing with medical concerns and being failed by the physicians treating them. In the last 18 months I’ve had more headaches than in the rest my life, they are localised with photosensitivity & nausea & last couple were a solid 8.5 on the pain scale, I am thinking migraine or cluster headaches, but know better than to suggest a diagnosis to a Dr. I began my conversation by reiterating that I’m in treatment for opoid use disorder & NOT seeking, nor can I accept a prescription narcotic, I’m concerned because of the recent onset of these headaches and their increasing frequency. Because I failed to express these ideas in the form of interpretive dance, they were unheard. ‘Because of your history of substance abuse & the fact that you are a methadone patient, I CANNOT & WILL NOT be able to treat you with controlled substance for pain. (!) I suggest you treat your headaches with ibuprofen (I had said I was taking motrin with coffee (when I can keep it down)) ice pack, dark room (basically repeating everything I told her I was doing up to now)
    Frustrated and feeling unheard, I restarted my concern is the recent onset & frequency and that if possible could I be referred for tests (unsaid: or perhaps referred to a doctor who listens to what I say)
    I was told COVID precludes any non emergency testing/treatments.
    My mother’s physician misdiagnosed a back injury as depression, my neice has a heart defect but her cardiologist downplays her symptoms because she’s young, until she collapsed,
    My apologies for the length here, THANK YOU Dr. For admitting that a doctor is still a person & is possible to not know everything, I so wish I could send the people I care for to be treated by you, but I don’t recon you do spinal medicine or cardiology in your spare time.

    Reply

  3. I believe that all prescribers should have to take the course to learn about both the disease and the proper use of buprenorphine. What would be nice is if the government would make it a completely free training.

    Reply

  4. Posted by King Diamond on February 7, 2021 at 8:45 pm

    Sounds like apologetics for another pathetic Biden decision to me. Unsubscribed.

    Sent from my iPhone

    >

    Reply

    • WHat? Too funny.

      Reply

    • Posted by Migraine on February 8, 2021 at 5:51 pm

      One can insert politics into absolutely ANYTHING I suppose. Yes, President Biden is PERSONALLY RESPONSIBLE for this change in licensing requirement. if you think back to debates it was his entire platform it’s all I ever talked about right?

      Reply

  5. Posted by Mark Wulff on February 9, 2021 at 8:01 am

    Interesting last comment, lacks logic and purely emotive, but interesting nonetheless.

    Dr Burson, you clearly stated that the rationales of experts on both sides of the decision are correct and that you are quite conflicted on which decision is best which, considering your experience and compassion for your patients, is saying something.

    One thing that everyone would agree on is this – you want what is best for the patients suffering and dying from OUD and the above ‘unsubscribed’ obviously had an axe to grind well before they read your article and they have no doubt moved on to a fresh target.

    Anyway, to your post 

    I find it surprising that the 8 hour course (and then some) hasn’t by now been included in a medical students training. Having said that, from reading the below article it looks like a gradual shift is occurring.

    I quote from an August 2016 article in Kaiser Health News (KHN) titled ‘Teaching Future Doctors about Addiction’.

    “Goodman can recall most of the lectures he’s attended at the Stanford University School of Medicine. He can recite detailed instructions given more than a year ago about how to conduct a physical.

    But at the end of his second year, the 27-year-old M.D.-Ph.D. student could not remember any class dedicated to addiction medicine. Then he recalled skipping class months earlier. Reviewing his syllabus, he realized he had missed the sole lecture dedicated to that topic”.

    The article goes on to say:

    Medical faculties have traditionally eschewed teaching about addiction, in part because many physicians viewed the subject as a personal vice, not a disease. Some consider it difficult – sometimes impossible – to treat in a medical setting”.

    https://khn.org/news/teaching-future-doctors-about-addiction/

    Reply

  6. Posted by Alan Wartenberg MD on February 11, 2021 at 8:27 pm

    It’s a tough issue. The main issue on the “pro” side is that some treatment is better than no treatment, which is what most of these folks end up getting. The “anti” side says that this population is marginalized and poorly understood, and that increasing the number of “ignorant” practitioners to care for them isn’t going to help. Agree with Jana that it’s a tough call. The real issue, though, is that the vast majority of people who take the course and get their waiver NEVER use it, and that those who do use it do so for a very limited number of patients. They are training residents in internal medicine and family medicine with the course as a requirement for completing their training, and offering them more mentoring as well.

    On a completely different note, I want to congratulate Dr. Burson for receiving the AATOD award for advocacy in our field. Richly deserved and late in coming!

    Reply

  7. Posted by Danny Resnick on February 22, 2021 at 11:14 am

    Hi Dr Burson. I am an NP who works with an addictions consult team in NY. We just started doing micro-inductions on bup for folks already on full agonist opioids. I have not tried it yet with methadone, but have seen a few case studies where it is successful. Seems to maybe be the future of induction. Saw one case study where it worked for a pt on 110 mg on methadone with zero precipitated w/d. Have you tried or heard of it?

    Reply

    • I’ve heard of a regional inpatient program that wants to try, but I have not seen the actual protocol or seen any data about success with such inductions. It is intriguing.

      Reply

    • Posted by David on March 8, 2021 at 5:52 am

      Hi Danny, Glad I saw your comment. I am an NP overseas. I have initiated buprenorphine microdosing, using patches, from methadone a few times now, with mixed results – none of them disastrous and sometimes highly successful. I have managed the transitions over a two week period. The worst that has happened is the client has experienced a couple of days of moderate discomfort around the end of week one or the beginning of week two (higher doses of patches or early doses with Suboxone); and the best that I have see is an easy transition from significant doses of methadone (around 80mg) to Suboxone and ultimately to Buvidal or Sublocade. I also know of successful transitions from higher doses (>100mg) of methadone. We have easy availability to long acting injections, and this is a big incentive for clients to consider making a switch.

      Reply

  8. Just wait a week and you will be reporting that this blog will be wrong by next week.X waiver is history within the week.

    Reply

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