Buprenorphine in the treatment of opioid addiction: opportunities, challenges and strategies

Li, Xiaofan; Shorter, Daryl; Kosten, Thomas R.

doi:10.1517/14656566.2014.955469

Cited by 27 publications

(25 citation statements)

References 77 publications

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“…[8][9][10] The only other national survey of physicians providing buprenorphine maintenance treatment 13 found that physicians with waivers whose names were found on a public locator list and those whose names were not reported financial concerns (59.3% and 71.8%, respectively), more often than they reported diversion concerns (18.7% and 26.3% respectively). Our findings show the opposite trend: more physicians, regardless of prescribing status, were concerned about diversion than finances.…”

Section: Discussionmentioning

confidence: 99%

“…5,6 A few studies, limited to 1 or only a few states, have looked at the barriers physicians face providing buprenorphine maintenance treatment, but none has examined nationally the differences between physician groups who are and are not actively using their waivers or accepting new patients. [7][8][9][10] This study's purpose was to understand the barriers physicians with waivers face in providing buprenorphine maintenance treatment.…”

Section: Introductionmentioning

confidence: 99%

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Barriers Rural Physicians Face Prescribing Buprenorphine for Opioid Use Disorder

2017

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Opioid use disorder is a serious public health problem. Management with buprenorphine is an effective, office-based, medication-assisted treatment, but 60.1% of rural counties in the United States lack a physician with a Drug Enforcement Agency waiver to prescribe buprenorphine. This national study surveyed all rural physicians who have received a waiver in the United States and found that those who were not actively prescribing buprenorphine reported significantly more barriers than those who were, regardless of whether they were treating the maximum number of patients their waiver allowed. These findings suggest the need for tailored strategies to address barriers to providing buprenorphine for opioid use disorder and to support physicians who are adding or maintaining this service. INTRODUCTIONT he opioid abuse epidemic is a serious and persistent public health problem. In 2015 an estimated 2.0 million people had a pain reliever use disorder, and 828,000 people had used heroin in the previous year.1 Buprenorphine maintenance treatment is effective for opioid use disorder, 2 and major efforts have been made to expand its availability. The Drug Addiction Treatment Act of 2000 allows physicians who complete training to obtain a Drug Enforcement Agency (DEA) waiver that permits prescribing buprenorphine to treat opioid use disorder. Despite a more than threefold increase in the number of physicians with a DEA waiver since 2006, 3 60.1% of rural counties lack a physician with a waiver. 4 Access to treatment continues to be a challenge for rural populations. Many physicians with a waiver are not using it to its full extent or at all. 5,6 A few studies, limited to 1 or only a few states, have looked at the barriers physicians face providing buprenorphine maintenance treatment, but none has examined nationally the differences between physician groups who are and are not actively using their waivers or accepting new patients.7-10 This study's purpose was to understand the barriers physicians with waivers face in providing buprenorphine maintenance treatment. METHODSWe surveyed all rurally located physicians in the United States on the DEA list (April 2016) who had received waivers to prescribe buprenorphine. We categorized physicians as rural using the Federal Information Processing Standards county code of the physicians' address if they had an Urban Influence Code of 3 through 12. 360nonrespondents using DEA, American Medical Association, National Provider Identifier, or Google Search result addresses until the physician's practice was found. Participants received the questionnaire at that address twice more, 2 weeks apart, followed by an abbreviated version of the questionnaire as a tear-off return postcard 1 month after follow-up began. Physicians responding to the tear-off postcard were not asked the barriers question. We telephoned nonrespondents up to 3 times, at 2-week intervals. Data collection occurred from July through November 2016.Physicians were classified into 4 categories based on whether the...

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Barriers Rural Physicians Face Prescribing Buprenorphine for Opioid Use Disorder

2017

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“…As is true with most pharmacotherapies for substance use disorders, one’s view of the effectiveness of buprenorphine depends on the question, “Compared to what?” There is no question that office-based buprenorphine treatment has been a significant advance in broadening the availability of an effective treatment for opioid dependence and has saved countless lives (9–12). Numerous reviews and meta-analyses underscore the strong effectiveness of buprenorphine in enhancing treatment retention and reducing illicit opioid use with respect to placebo or no treatment (13, 14).…”

Section: Overview Of the Four Trials Showing No Benefit Of Adding Coumentioning

confidence: 99%

“…Numerous reviews and meta-analyses underscore the strong effectiveness of buprenorphine in enhancing treatment retention and reducing illicit opioid use with respect to placebo or no treatment (13, 14). Buprenorphine’s important benefits also include reduced risk of HIV, sexually transmitted diseases, medical costs, and mortality (9). …”

Section: Overview Of the Four Trials Showing No Benefit Of Adding Coumentioning

confidence: 99%

The Role of Behavioral Interventions in Buprenorphine Maintenance Treatment: A Review

Carroll

Weiss

2017

AJP

180

123

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Objective Although counseling is a required part of office-based buprenorphine treatment of opioid use disorders, the nature of what constitutes appropriate counseling is unclear and controversial. We review the existing literature on the role, nature, and intensity of behavioral interventions in office-based buprenorphine treatment. Method Review of randomized controlled studies testing the efficacy of adding a behavioral intervention to buprenorphine maintenance treatment. Results Four key studies showed no benefit from adding a behavioral intervention to buprenorphine plus medical management, while 4 studies indicated some benefit for specific behavioral interventions, primarily contingency management. We examine the findings from the negative trials in the context of six questions: 1) Is buprenorphine that effective? 2) Is medical management that effective? 3) Are behavioral interventions that ineffective in this population? 4) How has research design affected the results of studies of buprenorphine plus behavioral treatment? 5) What do we know about subgroups of patients who do and do not seem to benefit from behavioral interventions? 6) What should clinicians aim for in terms of treatment outcome in buprenorphine maintenance? Conclusions High-quality medical management may suffice for some patients, but there are few data regarding the types of individuals for whom medical management is sufficient. Physicians should consider a stepped care model in which patients may begin with relatively non-intensive treatment, with increased intensity for patients who struggle early in treatment. Finally, with 6-month retention rates seldom exceeding 50% and poor outcomes following dropout, we must explore innovative strategies for enhancing retention in buprenorphine treatment.

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“…Importantly, between 2006 and 2010 (the time period during which our sample was recruited), only 8% of SUD treatment programs offered medication-assisted treatment (SAMHSA, 2011). Emerging evidence regarding the efficacy and safety of the partial agonist buprenorphine/naloxone (Gray, 2007; Li et al, 2014; Mattick et al, 2014) and intramuscular extended release formulation of the antagonist naltrexone (Gastfriend, 2011), may shift clinical perspectives, leading to greater likelihood of referral for SUD medication. For example, among SUD treatment seekers in 2012, 28% of primary heroin and 18% of primary non-heroin opioid patients reported engagement with medication-assisted treatment (SAMHSA, 2014).…”

Section: Discussionmentioning

confidence: 99%

The effects of continuing care on emerging adult outcomes following residential addiction treatment

Bergman

Hoeppner

Nelson

et al. 2015

Drug and Alcohol Dependence

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Background Professional continuing care services enhance recovery rates among adults and adolescents, though less is known about emerging adults (18-25 years old). Despite benefit shown from emerging adults’ participation in 12-step mutual-help organizations (MHOs), it is unclear whether participation offers benefit independent of professional continuing care services. Greater knowledge in this area would inform clinical referral and linkage efforts. Methods Emerging adults (N = 284; 74% male; 95% Caucasian) were assessed during the year after residential treatment on outpatient sessions per week, percent days in residential treatment and residing in a sober living environment, SUD medication use, active 12-step MHO involvement (e.g., having a sponsor, completing step work, contact with members outside meetings), and continuous abstinence (dichotomized yes/no). One generalized estimating equation (GEE) model tested the unique effect of each professional service on abstinence, and, in a separate GEE model, the unique effect of 12-step MHO involvement on abstinence over and above professional services, independent of individual covariates. Results Apart from SUD medication, all professional continuing care services were significantly associated with abstinence over and above individual factors. In the more comprehensive model, relative to zero 12-step MHO activities, odds of abstinence were 1.3 times greater if patients were involved in one activity, and 3.2 times greater if involved in five activities (lowest mean number of activities in the sample across all follow-ups). Conclusions Both active involvement in 12-step MHOs and recovery-supportive, professional services that link patients with these community-based resources may enhance outcomes for emerging adults after residential treatment.

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Buprenorphine in the treatment of opioid addiction: opportunities, challenges and strategies

Abstract: Buprenorphine can align addiction treatment with treatments for other chronic medical illnesses. However, preventing diversion will require graduate and continuing medical education and integrated care models for delivery of buprenorphine to those in need.

Cited by 27 publications

References 77 publications

Barriers Rural Physicians Face Prescribing Buprenorphine for Opioid Use Disorder

Barriers Rural Physicians Face Prescribing Buprenorphine for Opioid Use Disorder

The Role of Behavioral Interventions in Buprenorphine Maintenance Treatment: A Review

The effects of continuing care on emerging adult outcomes following residential addiction treatment

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