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Buprenorphine models must be re-examined

June 27, 2016
by Julie Miller, Editor in Chief
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Is buprenorphine a game changer? It depends, according to Bradley Stein, MD, PhD, senior scientist with RAND Corp., speaking at the Addiction Professional Summit in Pittsburgh.

Among the audience of some 350 management and clinical leaders, about half indicated by a show of hands that they offer buprenorphine at their centers. Nationwide, patient access to the pharmaceutical treatment varies and is not evenly distributed geographically, Stein noted, but the real gap that must be addressed is in the number of patients that each waivered physician actively treats.

One-third of waivered physicians aren’t treating any patients with buprenorphine. About 20% treat one, two or three patients, and half are treating less than 30—a far cry from the maximum 100 patients that they could be treating under current regulations. It stands to reason that expected federal policy changes to increase the cap to 200 will not suddenly make buprenorphine a silver bullet for the opioid crisis.

“It’s not just access. It’s really looking at treating people in a way so they get better,” Stein said.

Opportunity for greater reach

According to data collected by RAND from 3,200 waivered prescribers from 2010 to 2013 in seven states, the median number of patients treated is just 15.

“The caps are 30 to 100, and it suggests there is a tremendous opportunity there,” Stein said. “How can we increase capacity?”

When thinking about the anticipated federal policy to bump up the patient cap, the question centers around the degree to which the cap must be lifted to have a true effect on capacity, he said. Allowing physicians to treat more patients doesn’t necessarily mean they will follow through and do it.

A model created by RAND compared a number of levers that could be employed to optimize the use of buprenorphine. If the country set a goal, for example, of increasing buprenorphine treatment to an additional 400,000 people, then at the current trend of patient loads, the number of waivered physicians would need to almost double. The alternative would be for the currently waived physicians to double their patient loads.

Stein suggests that both options—increasing waivered physicians and increasing patient loads—must be kept on the table, with special attention paid to prescribers who treat low numbers of patients.

“So much of conversation has been about physicians and prescribers, but the conversation must expand to make sure there are counselors who can prescribe the therapy these individuals need,” he said.

Other healthcare specialties allow midlevel practitioners to prescribe—such as primary care nurse practitioners who can prescribe antibiotics, for example—so a similar model could be adopted in addiction medicine.