Academy keynoter: No cookie-cutter approach to buprenorphine treatment

Cost barriers to more widespread use of buprenorphine in the treatment of opioid addiction have begun to ease. Other obstacles, including the longstanding limit on how many patients a prescribing physician may treat at any one time, could take substantially longer to remove, and California addiction medicine specialist Matthew A. Torrington, MD, says he is learning to be patient.

“These things take a lot longer than anybody hoped they would,” says Torrington, who will deliver a keynote presentation on the past, present and future of buprenorphine at next month's Addiction Professional Academy on opioid addiction and pain management in Orange County, Calif. “Only the old and the wise realize how long it takes. The young and inexperienced, like myself, think everything is going to happen overnight.”

Maintaining the view that the glass is half full, Torrington points out that many more patients have access to medication-assisted treatment now that methadone is no longer the sole medication option. In addition, the availability of new and less expensive formulations of buprenorphine has broadened insurance coverage for the medication. Still, an exponential increase in the availability of medication options has not come close to meeting the overall need, Torrington says, and the federally imposed 100-patient limit on individual prescribers (30 in the first year) remains the primary barrier to expanded access.

“Can you imagine where endocrinology would be if each doctor could treat only 100 people on insulin?” says Torrington, a clinical research physician with Friends Research Institute/UCLA Integrated Substance Abuse Programs and medical director of Common Ground/End Dependence Free Clinic in Santa Monica.

Balanced message

Torrington says his Feb. 4 presentation at the Academy, an event on the treatment of opioid addiction and chronic pain that will run from Feb. 2-4, will emphasize the need for an individualized approach to treatment—there are no absolute answers that dictate how medication-assisted treatment, or any form of treatment for that matter, should unfold for everyone.

“I hope everyone can make it without medication,” Torrington says. “I'm just like the diabetes doctor who hopes all of his patients can do it with diet and exercise.” But some patients experience significant complicating factors to recovery, such as co-occurring mental health problems and the effects of trauma.

“But if you're on insulin, that doesn't show that you're a bad person,” he says, referring to the prevalent stigma around the use of medications in addiction treatment.

A key component of Torrington's presentation will state the case that the proper duration of medication-assisted treatment is the amount of time a patient needs to meet individual goals. Some patients will reach their peak of physical, emotional and spiritual balance quickly, while others run the risk of never getting there. The field has a clear understanding of some of the factors that can affect that pace, including the development of psychological coping mechanisms and the influence of one's social environment, he says. However, the effects of medications on drug craving can help offer a counterbalance even against the presence of significant negative influences in a patient's social environment, such as living amid drug activity.

“It's easy to pass on the bacon when you've just left the Ritz-Carlton buffet,” Torrington says. “You can't when you're starving to death.”

He adds that decisions around medication-assisted treatment for the individual should not be seen as static. “The decision on what's appropriate has to be made over and over and over again,” he says. “The decision you make today isn't necessarily the one you'd make in one month, three months or six months. It is not irrevocable.”

Unintended consequences

Torrington believes that in retrospect, it appears that the decision to spread out buprenorphine treatment over a wider universe of providers through the federal regulatory process was flawed, in that it brought more inexperienced providers into the mix and discouraged those who did not welcome the presence of the Drug Enforcement Administration (DEA) in their practices.

He thinks addiction counselors who work with the opioid-dependent continue to play an essential role in patient education around treatment, which is why he looks forward to next month's Academy presentation. “This is our infantry, our foot soldiers,” Torrington says. “We need them to be empowered.”