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SAMHSA Helps Bring Buprenorphine to the Field

By Rebecca A. Clay

Ask Anthony H. Dekker, D.O., about the ideal candidate for buprenorphine-based opioid dependence treatment, and he'll tell you the story of a patient who started injecting heroin again right after finishing a long prison sentence. Intent on turning his life around, the man came to the Indian Health Service facility where Dr. Dekker works and asked for help. Dr. Dekker's new patient had never heard of buprenorphine—a recently approved medication that alleviates drug cravings and eases the withdrawal of patients addicted to heroin, prescription narcotics, or other opioid drugs.

"Since this patient works 12 hours a day, the convenience of going to a local doctor's office for his medication was a big plus," said Dr. Dekker, Associate Director of the Phoenix Indian Medical Center in Phoenix, AZ. "Getting this man on buprenorphine means he has time to be involved in our support groups, sweat lodge, and a lot of other things. It's a way to help him get his life back."

Dr. Dekker is just one of many physicians around the country who are putting this new medication to use. Approved by the Food and Drug Administration (FDA) in 2002 and available in pharmacies in 2003, buprenorphine allows opioid-dependent patients to bypass specialized methadone clinics and—for the first time—seek treatment in the privacy of their own doctor's office.

To increase the number of physicians prescribing buprenorphine and thus increase patients' access to care, SAMHSA's Center for Substance Abuse Treatment (CSAT) is helping physicians get the training they need to prescribe the medication. The Center is studying how the new drug is actually being used in the field. And, the Center is developing resources to help physicians overcome some of the potential barriers to prescribing the medication.

"Buprenorphine allows physicians to treat opioid addiction just like they treat diabetes, hypertension, or any other chronic disease."

–Charles G. Curie, M.A., A.C.S.W.
SAMHSA Administrator

"Qualified physicians are now able to prescribe a therapeutic controlled medication in an office setting," said SAMHSA Administrator Charles G. Curie, M.A., A.C.S.W. "Now, buprenorphine allows physicians to treat opioid addiction just like they treat diabetes, hypertension, or any other chronic disease."

Training Physicians

Treating patients with buprenorphine involves more than just writing a prescription. To comply with the Drug Addiction Treatment Act of 2000, physicians who want to prescribe the medication for use in detoxification or maintenance treatment must first obtain a waiver from SAMHSA that exempts them from certain Federal requirements related to the prescribing of controlled substances. To qualify for the waiver, licensed physicians must have subspecialty board certification in addiction medicine or undergo at least 8 hours of approved training in buprenorphine use.

To help physicians meet these requirements, CSAT funded the development of a curriculum to be used in these 8-hour training sessions. A consensus panel of addiction medicine experts representing three medical societies—the American Academy of Addiction Psychiatry (AAAP), the American Osteopathic Academy of Addiction Medicine (AOAAM), and the American Society of Addiction Medicine (ASAM)—developed the curriculum.

Use of Buprenorphine in the Pharmacologic Management of Opioid Dependence: A Curriculum for Physicians gives trainers an easy way to prepare lectures and other educational activities related to buprenorphine treatment. The curriculum includes sample slides and sample questions trainers can use to develop pre- and post-training tests, for instance.

"The goal of the curriculum is to provide a structured, uniform set of materials that address a variety of important issues in the treatment of opioid-dependent patients," said David A. Fiellin, M.D., an associate professor of medicine at Yale University Medical School, who helped write the curriculum in his role as chair of ASAM's Buprenorphine Training Subcommittee. "We wanted to develop the curriculum in such a way that it would be appropriate for both specialists in addiction medicine and generalists."

To meet those goals, the curriculum begins with an overview of the legislation and pharmacology behind buprenorphine as well as a discussion of nonpharmacological treatment of opioid-dependent patients. Another section explains how to assess and select patients for treatment, including discussions of what to do when a patient has other psychiatric or medical problems beyond opioid addiction. A large part of the curriculum focuses on the logistical aspects of buprenorphine treatment, including sections on protecting a patient's privacy, establishing appropriate office policies and procedures, and keeping good medical records. The curriculum concludes with several case studies.

Estimating that trainers use about 80 percent of the curriculum's slides in their current form, Dr. Fiellin noted that he and other trainers are already modifying the slides or adding slides of their own. When Dr. Fiellin gives trainings, for example, he adds information about incorporating psychosocial treatment into an office-based setting. Dr. Dekker's trainings feature more detailed information about prescription drug abuse than the basic curriculum offers.

Using the Curriculum

doctor greeting patient In addition to funding the curriculum's development, CSAT is providing support for the trainings where Dr. Fiellin, Dr. Dekker, and other experts use the curriculum. Buprenorphine's manufacturer recently decided to provide additional funding for training. Sponsored by the three medical societies involved in the curriculum's development as well as the American Psychiatric Association (APA), these ongoing training events are taking place nationwide. AAAP and APA also offer Web-based instruction that allows physicians to get their training online.

As of February, 3,722 physicians had been trained in the use of buprenorphine.

So far, the trainings have attracted addiction specialists who technically don't need the training but who want to learn more about buprenorphine. Trainings also attract primary care physicians. "Most physicians are not addiction specialists. The more we can get primary care physicians interested in taking a course, the greater the likelihood they will become interested in treating this population," stated H. Westley Clark, M.D., J.D., M.P.H., CSAT Director.

Now CSAT is reaching out to other organizations that can help bring in more physicians. The Health Resources and Services Administration's HIV/AIDS Bureau, for instance, is working to convince physicians that treating opioid addiction can enhance prevention as well as adherence to HIV treatment regimens. CSAT is also working with ASAM and other organizations to educate physicians involved in pain management about buprenorphine's role in treating patients addicted to prescription narcotics.