In 2002, a group of researchers for the American Psychiatric Association surveyed a random sample of 2,323 psychiatrists to explore attitudes toward office-based prescribing of the opiate agonist buprenorphine (Am. J. Addict. 2004;13[suppl. 1]:8–16).
Only about half of the sample–1,203–responded, and of those, 81% expressed discomfort with the idea of incorporating such treatment into their practices, highlighting what the authors called “significant barriers” to extending addiction treatment into the larger psychiatric community.
Not much has changed since then, although the need is undeniably huge.
Current estimates hold that there are 1 million heroin users and 3 million people addicted to prescription opiates in the United States today, balanced against a total of 220,000 slots in methadone clinics.
“The simplest math shows that we are many orders of magnitude out of sync, considering the number of patients and the number of slots available,” said Dr. Thomas Kosten, former director of the U.S. National Buprenorphine Implementation Program, and currently the chair of psychiatry and behavioral sciences at Baylor College of Medicine in Houston. “We've hardly touched the problem.”
Even if the number of methadone slots were to increase exponentially, stigma keeps many people addicted to opiates away from seeking treatment, he said.
“Many of them are not heroin addicts, and they wouldn't be caught dead going to a methadone clinic,” Dr. Kosten said.
And yet, the promise of an alternative has failed to take off in the United States, with only about 300,000 people receiving prescriptions for buprenorphine since its introduction in 2002 under the Drug Addiction Treatment Act as the first office-based treatment for opiate addiction.
Buprenorphine is a long-term opioid agonist that has been shown to reduce cravings and block the effects of opioids, while limiting the potential for overdose.
Addiction specialists make up almost half of the current prescribers of the drug, and many of the others who have undergone required government-sanctioned training are primary care physicians.
General psychiatrists continue to be decidedly lukewarm about the idea.
The hope was that “buprenorphine prescribing would expand to a broader population of physicians, to provide better access to a highly motivated group of patients [many of whom are addicted to prescription opiates],” said Dr. Cindy Parks Thomas, a researcher at the Brandeis University Schneider Institute for Health Policy, Waltham, Mass.
But when she and associated researchers questioned in depth 271 addiction specialists and 224 general psychiatrists in 2005 and 2006, they found that the latter group generally lacked familiarity with, and interest in, being a part of what had been conceptualized as a revolutionary shift of addiction treatment from licensed methadone clinics to office practices (Psychiatr. Serv. 2008;59:909–16).
They found that although 90% of addiction specialists were prescribing buprenorphine, less than 10% of general psychiatrists were doing the same.
About 1 in 6 non–addiction specialists reported that they had not heard of buprenorphine, and others reported barriers, including: “It does not fit in with my practice,” “It would change the patient mix undesirably,” and “Prescribing is too complex.”
They also worried about the cost of initiating such treatment and the financial impact of the shift on their practices.
Dr. Thomas explained In a telephone interview that such concerns often are allayed in physicians who train through the Substance Abuse and Mental Health Services Administration (SAMSHA) and actually begin treating patients.
“It was curious…that in our study, so few general psychiatrists were interested, even though our sample was limited to physicians already treating drug addicted patients,” she said.
Some psychiatrists, ironically, might have feared that too many patients would come to them for buprenorphine, despite limits on the number of patients that qualified physicians can treat in their practices.
“They didn't want drug-addicted patients calling their offices and sitting in their waiting rooms…next to middle-class families they were treating for anorexia,” she said.
In fact, both Dr. Thomas and Dr. Kosten said patients who seek office-based treatment for opioid addiction tend to be quite different from the stereotypes of addicts overdosing in the emergency department or hanging around the parking lot of a methadone clinic, waiting for a fix.
“They say thank you, they don't steal your computers, and they want to change their lives,” Dr. Kosten said.
In general, they do well with weekly, then monthly, 15-20 minute visits for renewal of their prescriptions and brief, structured therapy, much of which could be handled by “people who work a lot cheaper than we do,” such as social workers, family therapists, or psychologists.
In contrast to many psychiatric patients who struggle for years with their disorders, patients seeking office-based treatment “feel better almost immediately and in a few weeks, they feel cured,” he said.