Despite being at the front lines in the nation's battle against opioid addiction as the first to treat chronic pain, and opioid overuse, few primary care and family physicians use the one drug available to them to treat addiction, buprenorphine, experts say.
"Sublingual buprenorphine is the only treatment for opioid addiction that can be provided by primary care providers [PCPs], yet it's rarely used by them and the demand for it is enormous," said Lucinda Grande, MD, from the University of Washington's Department of Family Medicine, in Seattle.
"Primary care is an ideal place for this drug to be used, with PCPs being the ones treating most of the chronic pain out there," she said. "Many of our patients are not thriving on opioids, and PCPs have been struggling to find a better option for them."
"These are already our patients; we have longitudinal relationships with these patients and we are very tuned in to their family and social contexts," Dr Grande added. "This supportive relationship is so helpful for patients with chronic pain."
This issue was the topic of a highlighted symposium here at the American Pain Society (APS) 35th Annual Scientific Meeting.
Waivers to Prescribe
To prescribe buprenorphine for opioid addiction, physicians are required to obtain waivers from the Drug Enforcement Administration (DEA), but the number of primary care physicians with the certification is low, she said.
Dr Grande noted that a recent study, published last year in the Annals of Family Medicine, indicated that as few as 3% of PCPs were listed on the July 2012 DEA Drug Addiction Treatment Act (DATA) Waivered Physician List.
In fact, only 2.2% of all US physicians had the waiver, the study showed. Among those, 46% were psychiatrists, 37% were PCPs, and 27% were in other specialties.
Another study, published last year in Rural Remote Health, underscored the imbalance of need vs access to buprenorphine maintenance treatment in the primary care setting.
In the survey of 108 family physicians in Vermont and New Hampshire, the authors, from the Geisel School of Medicine at Dartmouth College, in Hanover, New Hampshire, found that, strikingly, more than 80% of respondents reported regularly seeing patients addicted to opiates, and 70% said they felt as family physicians the responsibility to treat opiate addiction.
Yet only 10% were buprenorphine prescribers.
Key factors reported in the study as potential barriers to adoption of buprenorphine included inadequately trained staff (88%), insufficient time (80%), inadequate office space (49%), and cumbersome regulations (37%).
Dr Grande commented that the study underscores that "imagined barriers may be greater than the real ones."
"I would advise physicians to seek input from experienced prescribers, such as through the online web-based resource called the Providers' Clinical Support System– Medication Assisted Treatment. (http://www.pcssmat.org)
The DATA waiver is not required to prescribe buprenorphine for pain — it is needed only for addiction, Dr Grande said. "But insurance will usually not pay for the drug when it's prescribed for pain. This is because of a technicality. Prescribing the high-dose sublingual form — which is FDA [Food and Drug Administration]-approved to treat addiction — is not FDA-approved to treat pain."
The certification, which involves just 8 hours of training, provides very helpful information on legal issues and pharmacology the drug, she said.
With a pressing need for more physicians with the DATA waivers, Dr Grande expressed the hope that the waivers to prescribe buprenorphine for addiction will at some point extend beyond physicians.
"Availability to patients would be much better if nurse practitioners and physician assistants were able to prescribe the drug," she asserted. "But this will literally take an act of Congress." The rules were set by DATA, which was a congressional act.
Though an opioid itself, buprenorphine, a partial agonist, has a high binding affinity at the μ-opioid receptors, allowing the drug to counter the effects of full agonist opioids, such as morphine, blocking the euphoria and having a significantly lower risk for respiratory depression or overdose.
"Buprenorphine wipes out withdrawal and craving, it reverses sedation and actually turns it into activation, making people want to get out and become active," Dr Grande explained.
"The transformation you see in patients with this is unbelievable."
Among the 70 patients that Dr Grande said she has on buprenorphine, approximately half are primarily being treated for addiction and the other half, for pain, but there is overlap, with some patients being treated for both.
Patients who are ideal candidates for buprenorphine include those being treated with long-term opiates who are showing the red flags of problematic behavior and possible addiction.
"When they come to you for that next early refill — because it is the early refills that indicate a problem, you tell them you can't, but you say 'what I can do is offer you this other medicine that I think will really do a better job for you in the long run.'"
"I don't push it but will raise the issue and when they do accept it, patients are almost always happy with the change."
Jonathan Daitch, MD, medical director of Advanced Pain Management & Spine Specialists, in Fort Myers, Florida, who also spoke on the issue during the symposium here, noted that when his patients show signs of opioid overuse and resist the switch to buprenorphine, he doesn't give them a choice if they want to continue treatment at his practice.
"At some point we have a behaviour discussion and I have to tell them I can't tolerate this behavior. If you want me to continue to treat you, you either have to convert to this safer drug or find another doctor."
Dr Daitch added that patients need to be educated about the spectrum of symptoms that are more the result of opioid overuse than the chronic pain that the opioids are being used to treat. He highlighted hyperalgesia, which he described as an increased sensitivity to pain that is typical in patients on high-dose opioids.
Dr Daitch said he had converted about 1000 patients from traditional opioids to buprenorphine. "The key to converting patients to buprenorphine is to educate them that they are treating withdrawal and not pain." He said he doesn't need to use his DATA waiver because he is actually treating pain. Most of these patients do not have a true addiction.
"They need to know that much of what they are feeling is not pain but a drug-induced withdrawal syndrome, and if the circular behavior of the opioid overuse can be broken, their pain would be significantly improved."
"You have to be careful transitioning patients from methadone. You have to wait 5 half-lives for the opioid to be eliminated from the body," he said.
"I like to put them on oxycodone for 5 days to make an easy transition to buprenorphine."
Dr Daitch noted that buprenorphine's analgesic effect increases over the first week of treatment. "The brain needs time to reset its pain sensitivity perception and threshold," he said.
"Pain and withdrawal symptoms decrease as the week continues, and those who really want to get better tend to do just fine."
Dr Grande and Dr Daitch have disclosed no relevant financial relationships.