The trick is to ensure that they have the support to help them make the significant changes in friendships, jobs, and living circumstances to be able to truly shift away from an addiction lifestyle and toward focusing on long-term goals, a process that usually takes 2 years or more.
Primary care physicians have been far more interested in taking on opioid addiction in their practices than have general psychiatrists, and numerous studies have documented success in terms of patient retention and control of opioid use.
One such recent study found that a year into treatment, nearly 60% of 255 patients remained in treatment at a primary care practice, testing opioid negative (during urine screens) 65% of the time (J. Subst. Abuse Treat. 2009;37:426–30).
Dr. Kosten said primary care physicians are more accustomed to the quick-visit model for patients with chronic disease and also more interested in treating the myriad comorbidities that come with opioid addiction, among them chronic pain, hepatitis C, and HIV.
It could take some “rethinking” for general psychiatrists to catch on to the opportunity in what he predicts will be an “onslaught” of patients addicted to prescription painkillers who also might have psychiatric comorbidities.
To be sure, buprenorphine prescribing can be challenging, as Dr. Theodore V. Parran and associates learned when they began implementing such a program at St. Vincent Charity Hospital in Cleveland.
“We found out very early in the process that expectations…had to be made clear and nonnegotiable at the time of initiation of buprenorphine, Dr. Parran, an internist, said in an interview. “Otherwise, patients never did treatment and just wanted medication.”
After those guidelines had been established, the program's goal of “full-out patient recovery” was met by nearly 50% of the patients–an “astonishing” success rate, he said.
Dr. Thomas noted that the government-supervised buprenorphine program also was dogged by diversion of the drug for street sales.
Bad publicity on black market sales and abuse patterns might have made some physicians even more reluctant to become involved. However, she said, when psychiatrists see a few colleagues succeeding in treating addiction from their offices, they might be more willing to sign on for a training course and give it a try.
“In a way, a rising tide lifts all boats,” she said. “Every year, more physicians have applied for the waiver [that permits them to prescribe buprenorphine to patients in an office setting].”
Dr. Kosten has served as a consultant to Reckitt Benckiser Pharmaceuticals Inc., the maker of buprenorphine; Dr. Thomas said she has no disclosures; and Dr. Parran has been an organizer and presenter for the SAMHSA pain and addiction courses and is on the speakers bureau for Reckitt Benckiser.
By Betsy Bates. Share your opinions at cpnews@elsevier.com
Most patients on buprenorphine do well with brief, weekly office visits, Dr. Thomas Kosten said.
Source Courtesy Dr. Thomas Kosten