An Interview with the ATTC

For those who missed it, I recently provided some opinions about buprenorphine treatment for The Bridge, a journal produced by the Addiction Technology Transfer Center Network.  The discussion was published in The Bridge Volume 4, Issue 3, and is copied below.

Question 1. The introduction to buprenorphine treatment in the U.S. has occurred through a controlled system somewhat parallel to controls on methadone. How would you envision the current buprenorphine treatment scene had these regulations never been imposed, with buprenorphine introduced into medical care with no waivers or patient limitations?

Dr. Junig:  I think it would be different in good and bad ways. Without the regulations, buprenorphine would likely have become prescribed by primary care to a much greater extent, which would have saved the lives of many, many young people. There would be more buprenorphine/Suboxone in the hands of patients and non-patients. The increase in buprenorphine would likely be balanced by reductions in opioid agonists, as primary doctors would have moved chronic pain patients from agonists to buprenorphine. Any reduction in use of opioid agonists would be a good thing, whether through reducing the deaths caused by agonist diversion, or through getting people stuck on the roller-coaster of agonist dependence onto buprenorphine instead. While buprenorphine has similar discontinuation symptoms as agonists, the subjective experience of taking buprenorphine is very different from the experience with agonists—leaving people much better off after the change.

The addiction doctors who seem to see diversion-control as their primary role would see an increase in buprenorphine/Suboxone as a problem. But the dangers of buprenorphine diversion are overblown. Much ‘diversion’ consists of misguided self-treatment by patients who can’t find a prescriber, or by former patients who were not able to maintain sobriety perfectly-enough to avoid discharge from their prescriber. Having more prescribers might have resulted in less non-prescribed use of buprenorphine.

The diversion issue is complicated, even in cases where buprenorphine is used as a bridge between agonists in addicts who do not intend to quit using. Buprenorphine has a strong protective effect against death, whether taken by prescription or through diversion. Specifically, over 35,000 US overdose deaths occur annually in the absence of buprenorphine, compared to about 40 overdose deaths each year when buprenorphine is one of the drugs in the person’s system. If the people most worried about diversion are correct—i.e. if diversion consists less of ‘self-treatment’ than of poly-substance dependence– we would expect many more overdose victims to have buprenorphine in their bloodstream at the time of death. The bottom line: if a person takes buprenorphine for any reason— even just to avoid withdrawal until a better batch of heroin comes to town— that person is less likely to die from overdose.

Question 2.  It is recognized that there are some geographic locations where buprenorphine access is highly limited. Aside from this troubling fact, a devil’s advocate could argue that the numbers of physicians who have been waivered represents a major success. Most of the “folklore” of the field would have suggested that practically no physicians would have wanted to come forward to treat opiate addiction.

Dr. Junig:  The ‘folklore’ is, unfortunately, largely correct. Many waivered physicians never actually prescribe buprenorphine products. Others start treating opioid dependence but then discontinued that aspect of their practice. Last weekend, headlines in Indiana described the arrest of several doctors who prescribed buprenorphine products. News stories demonized aspects of their practice styles, even though they were not at odds with DATA 2000. The articles wrote that (gasp!) they were not doing urine tests at every patient visit, they were asking for cash payments, and they didn’t require counseling for every patient. The lack of ASAM support for these physicians and similar cases will have a chilling effect on physician attitudes toward treating opioid dependence.

Question 3.  Would there be any disadvantages if the current patient limit of 100 was eliminated altogether?

Dr. Junig:  Many lives would be saved. Some doctors picture a sea of buprenorphine abuse, but patients who take the medication know that a ‘buprenorphine habit’ does not yield the experience achieved with heroin or other agonists. The ceiling effect results in constant opioid activity across the dose range, which leads to rapid tolerance— whether the buprenorphine is injected or taken sublingually. For opioid agonist addicts, the primary result from buprenorphine abuse is inadvertent treatment!

Question 4.  From your perspective, how successful have physicians been in linking buprenorphine patients with psychosocial counseling?

Dr. Junig:  Successful enough. Some patients do well on buprenorphine products without counseling. While that statement is almost heresy these days, I encourage addiction doctors to do the specialty the favor of practicing evidence-based medicine, and following the data. Buprenorphine treatment is filled with a range of opinions about best practices. But where are the data?

Question 5.  Simply on the basis of their skills as physicians, and assuming they were willing to spend the time, do you think the majority of physicians could successfully deliver this psychosocial counseling?

Dr. Junig:  Many different interventions fall under the label of ‘counseling’. If a counselor spends each session trying to convince a patient to ‘get off buprenorphine’, is that effective counseling? Any physician who knows his/her patient, and cares enough to counsel, educate, and refer appropriately, should be allowed to decide what is best for the patient. Surgeons are given the responsibility to decide, all by themselves, which organ to remove—but addiction doctors aren’t trusted to make decisions about counseling? No other medical specialty assumes such a high level of ignorance in their doctors!

Question 6.  From your perspective, how successful have physicians been in delivering other needed medical services (services they likely would not otherwise receive) to the patients to whom they prescribe buprenorphine?

Dr. Junig:  Practices vary. I have great respect for primary care physicians who manage opioid dependence, and at the same time manage other forms of illness in the same patient. In other areas, addiction doctors have become ‘super-specialists’ who only provide buprenorphine treatment. I know that in my own practice, patients who initially present for buprenorphine treatment end up with much better psychiatric care than they otherwise would have received.

Question 7.  Has your buprenorphine practice added significant numbers of new primary care patients to your overall practice?

Dr. Junig:  I am a psychiatrist, and buprenorphine has added new psychiatric patients. I also evaluate rashes, infections, aneurysms and pseudo-aneurysms, GI issues, and many other conditions outside of psychiatry that have some connection to the patients’ buprenorphine treatment.

Question 8.  On the basis of your own experience and the experience of your colleagues, has the presence of patient addicts in your practice caused difficulties with other patients or with your colleagues/staff?

Dr. Junig:  I suspect some non-addiction patients have been uncomfortable in the presence of patients with addictions who are new to treatment, who sometimes appear a bit rough. I encourage patients to talk about their concerns, and I do not believe I’ve lost patients over that issue.

Question 9.  What key indicators should determine when tapering off buprenorphine should begin?

Dr. Junig:  Given the high rate of relapse, I believe patients have a right to ongoing buprenorphine treatment without time limitation. I advise patients about the risk of relapse. We need more data, but I suspect that age, occupational status, and personality factors play a role in risk of relapse, and should therefore be factored into decisions about discontinuation of buprenorphine.

Question 10.  What are the prospects for insurance coverage for indefinite/as needed maintenance on buprenorphine?

Dr. Junig:  I believe prospects will be good, IF our professional advocate agencies step up to the plate and educate insurers—and legislators. We should demand access to lifelong medication for our patients with lifelong illnesses!

Question 11.  For currently active buprenorphine-waivered physicians, what should they be considering in terms of the use of injectable naltrexone for their opiate addicted patients?

Dr. Junig:  Naltrexone looks good on the surface, but too few people consider the long-term outcomes. We seem to have a fantasy that if we block a person from using for a year, counsel the heck out of the person, and then remove the block, that the patient will live happily ever after. But Australian studies show high death rates in patients who were maintained on naltrexone in the year after naltrexone was discontinued. Since we have no data showing that counseling is effective in maintaining abstinence from opioids, I am not convinced that it is a good idea to keep someone from his drug of choice with monthly injections, and then stop those injections—particularly when the injections create hypersensitivity to opioids and respiratory depression from opioids. Patients stop Vivitrol knowing that IF they relapse, they will get the biggest ‘high’ they’ve ever had… which is not a good situation for addicts! Will there be a high death rate in people who were placed on naltrexone, when the drug is discontinued? I suspect the answer will be ‘yes’—but in either case, I hope that physicians pay attention to that data.

Question 12.  If you found yourself appointed Czar of All Drug Treatment in the U.S., what steps would you take to improve the delivery of buprenorphine to opiate-addicted patients?

 Dr. Junig:  I would ask physicians to practice medicine first, and to follow the science. We have a role in preventing diversion, but that is not our primary role as physicians. Physicians should point out, and resist, any regulation or policy that increases the number of deaths from opioid dependence. Who will carry that message if not physicians?

When physicians become obsessed with out-regulating each other, the result has been policies based on opinions or business models, not on science. Some of the policies being advocated– for example quantitative testing or counseling for all patients— have large profit incentives for doctors and health systems, but stand in the way of care for uninsured or underinsured patients.

I would want to see opioid dependence treated as the disease that it is. With any new regulation, we should ask ourselves: would we do the same for asthma or hypertension? Do we require nutrition counseling, for example, in order to receive insulin? I would also assume that doctors treating addiction have the same intelligence, competence, and compassion to stay current with the standard of care for treating addiction, as any other physicians. We shouldn’t add regulations that would not be tolerated by any other medical specialty.