Be wary of lifting cap on buprenorphine patients, AATOD paper warns

Because some physician practices fail to offer the comprehensive services needed in conjunction with medication for treating opioid addiction, policy-makers should proceed cautiously before considering a lifting of the cap on the number of patients an individual prescriber can treat with buprenorphine, a new policy paper from the American Association for the Treatment of Opioid Dependence (AATOD) suggests.

AATOD states that its paper, dated July 2, is designed to raise several questions in an attempt to stimulate thoughtful policy discussion on opioid addiction treatment, at a time when the urgency of this public health crisis has policy leaders across the country scrambling for solutions. One of the most talked-about areas that the paper addresses is the patient cap that the federal Drug Addiction Treatment Act of 2000 (DATA 2000) imposed on medical practices authorized to prescribe buprenorphine—a ceiling that started at 30 patients per physician and then was increased to 100 after the first year.

AATOD, which represents nearly 1,000 opioid treatment programs (OTPs) that mainly use methadone in their medication-assisted treatment regimen, says in the paper that more needs to be known about the extent and quality of care in physician practices before any major policy shift on patient caps is advanced. Some of the questions the association says need to be asked are, “What do we know about what goes on in a DATA 2000 practice? What percentage of physicians refers patients for counseling and other services? How many DATA 2000 practices are organized to provide such counseling to the patient on site?”

The paper adds, “If we know that there are medical standards in treating such an illness, they should be followed. When quality treatment interventions are sacrificed at the hands of quantity, the integrity of the treatment intervention is inevitably questioned.”

Assessing the crisis

The paper, “Increasing Access to Medication to Treat Opioid Addiction — Increasing Access for the Treatment of Opioid Addiction with Medications,” offers an overview of clinical guidelines for opioid addiction treatment and seeks to provide clarity on emerging trends in opioid misuse and its treatment. It cites the National Institute on Drug Abuse's (NIDA's) assertion that medications can be an important component of treatment when combined with counseling and other behavioral therapies, and states that the complexities of opioid addiction make single-site treatment interventions the ideal approach for patients.

Regarding the issue of many opioid users now crossing over from one type of drug to another, the paper states, “It has also been reported that an increasing number of individuals are using heroin when their preferred prescription opioids are no longer available. This is still a developing issue so it is too early to refer to this as a trend.”

The paper also comments on the emergence of harm reduction approaches such as needle exchange programs and widespread use of naloxone as an overdose prevention measure, stating that these interventions will ultimately succeed when the targeted individuals are linked to treatment programs as well.

On the controversial topic of whether buprenorphine treatment is being marred by significant diversion of the medication, the policy paper calls this “a complex topic which needs further evaluation.” It states, “There is also a current policy debate about the fact that such diverted buprenorphine is being used therapeutically by people who cannot gain access to treatment. This perspective takes the view that the nation and its officials should not be concerned about reports of buprenorphine diversion because it is being used safely by such individuals. There are no published reports to support this point of view, although a number of people who are using buprenorphine through illicit means may be doing so to prevent withdrawal until they are able to access their preferred opioid.”

Cap-related strategies

AATOD offers some alternatives to increasing the DATA 2000 practice cap on buprenorphine treatment. In order to increase treatment capacity in other ways, the government could include mid-level practitioners in DATA 2000. Alternatively, it could allow DATA 2000 practitioners to convert to an OTP structure, which then would subject them to stricter federal regulations and oversight that would result in a more comprehensive approach to care, AATOD indicates.

The paper concludes, “In spite of the fact that we are clearly facing a public health crisis of opioid addiction, we need to develop thoughtful solutions based on what research and clinical practice have demonstrated over the past 50 years.”