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Increase Access to Buprenorphine, Senators Urge Federal Officials

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Pharmacist prescription 6-19-14

Two U.S. senators this week urged federal officials to expand access to buprenorphine to treat heroin and painkiller addiction.

Buprenorphine helps control drug cravings and withdrawal symptoms, but remains underused a decade after it was approved, the Associated Press reports. It can be prescribed as a take-home medicine, unlike methadone, which must be administered in a clinic. Buprenorphine has a lower risk of overdose and milder side effects, the article notes.

Federal law restricts buprenorphine prescribing, and insurance coverage of the treatment is inconsistent, according to the AP.

“We’ve heard remarkable stories of success with buprenorphine treatment, of lives saved and families rebuilt from the ravages of addiction,” Senator Carl Levin of Michigan said in a news release. “But we have also heard stories of frustration at the fact that many patients want this treatment but can’t get it, and we need to remove those hurdles.”

In 2000, Levin and Senator Orrin Hatch of Utah sponsored the Drug Addiction Treatment Act (DATA 2000), which made it legal for doctors to prescribe buprenorphine for up to 30 patients at a time in their offices. The Food and Drug Administration approved the drug’s use in 2002. Subsequently, the patient limit was raised to 100.

Senators Levin and Hatch hosted a forum Wednesday to examine impediments that prevent greater access to buprenorphine, and to explore changes that could help expand access. The American Society of Addiction Medicine has proposed raising the patient limit to as high as 500 for doctors who complete 40 hours of training, the article notes.

Some federal officials said they do not want to raise the patient limit because buprenorphine can be abused. Dr. Nora Volkow, Director of the National Institute on Drug Abuse, said buprenorphine overdoses are common in Europe, where the drug is more available. Raising the patient limit could lead to buprenorphine “pill mills,” some officials noted at the forum.

26 Responses to this article

  1. Rob / July 8, 2014 at 1:23 pm

    I can personally attest to using suboxone (buprenorphine) to get off my year long binge of using and abusing opiates and other drugs for speed. I was up to 20 percocets a day, plus 3, 30mg roxies and cocaine to top that off to keep me going. I’m sure I would be dead now. Not so sure my liver or other organs are at their best performance, but its my own fault. I started what would last be a total of 3 months of suboxne, taking only 1 – 8mg tab per day, on week 3, half of that, then week 5, I switched to the strips under tongue. It wasn’t the same and I felt withdrawals, however, I wasn’t keeping it under my tongue long enough. Once I realized that, I was back down to lowering my dose to a 3rd of the 8mg strip, all the way down to (I haven’t even run out) YEAH, I just stopped it and I am perfectly fine.

    It works, BUT – you’ve gotta have the will power and desire to stop using to have a life of sobriety. Unfortunately, many people go from one extreme to the next. 20 pain pills per day to shooting up buprenorphine.

    The buprenorphine in itself is another addicting drug, but if you have the will power, YOU CAN STOP USING. Life is AWESOME… Remember what it was like to feel normal and have a clear mind. YOU CAN DO IT.

    If there is better access and lower costs, I do feel that more people would be drug free.

    Rob
    RecoveryHub.com

  2. Angel Gonzalez, MD / June 21, 2014 at 10:00 pm

    What? Can’t distinguish a drug from a medication? Don’t know bup’s mechanism of action? Are not aware of neurobiological changes in the brain that cause withdrawal and cravings after the opioids are withdrawn and these changes are already there when the bup is started, obviously not caused by bup.
    This position totally ignores the science behind medication assisted treatment which includes comprehensive assessment and psychosocial management. As I tell my students, it is quite difficult to do counseling and address other issues with a person in withdrawal. This is why MAT is so efficacious compared to “detox” and non medication in opioid dependent persons. http://www.drugabuse.gov/publications/topics-in-brief/medication-assisted-treatment-opioid-addiction

  3. Kevin Weikum / June 20, 2014 at 1:55 pm

    I am an addiction professional with nearly 4 years of experience working with approximately 100 bupe patients. While the results are mixed, the advantages and successes I’ve seen far exceed the disadvantages. Those who have no real desire to recover, typically don’t. Those who are sincere have regained their lives, families, careers and successes. Why? Because they know they have a disease and responsibly treat it with medication that works. There is nothing new about that concept. Some of these patients have been sober in excess of 10 years and the quality of their lives is evidenced by that fact.
    Is medication a cure for any chronic disease? No! Is bupe necessarily a panacea? No! Does it work for everyone? No! The same can be said for any disease medication is used to control. There are side effects of spontaneous cessation, but that can be said about many maintenance medications which require titration for discontinuation. This one is no different, and not every patient who spontaneously ceases experiences severe withdrawal symptoms. Some do, some don’t.
    People find different methods for recovery and it should remain a personal choice as to what recovery means from one individual to another. If a person, by taking medication, can legally pursue their everyday activities by acceptable standards and be happy and healthy; instead of illegal, unacceptable and life threatening behaviors, I not only fail to see the harm, but applaud the choice. Complete abstinence is great and works for many, but obviously not all. Recovery, like the disease, is progressive and never ending. One is either recovering or relapsing. If bupe enables one to continue the pursuit of this lifelong process, perhaps with continuing effort, that one will someday attain abstinence and be free from the medication. At least the medication provides the clarity and health needed to continue down the pathway of recovery while maintaining an acceptable standard of living and productivity.
    In my opinion, the single greatest drawback of the medication is its availability to those who need it the most. It remains too far out of the reach of most opiate addicts, therefore, it fails to even be an option for them. It disgusts me that its purveyors seek its profits more than its benefits, like the proverbial carrot which hangs at the end of an unreachable stick. Its a shame that the present system makes it easier to remain addicted then to get the help by which everyone can benefit.

  4. Richard Bennett M.D. / June 20, 2014 at 1:16 pm

    drugfree.org 6/20/2014

    Suboxone is an amazing drug.

    This singularly effective and safe drug rescues lives and families in a very high percentage of those afflicted individuals who enter and are maintained on this therapy.

    Side effects are essentially negligible, and patient function is fully restored.

    If Suboxone had been available for the treatment of opiate (narcotic) addiction before methadone, methadone would have never been approved for this purpose.

    Suboxone has the following advantages over methadone:

    1) Suboxone is a completely different drug from the standard pain and abuse narcotics such as methadone, heroin, Percocet, Lortab, Oxycotin, morphine, ect..

    2) Patients cannot fatally overdose on Suboxone alone, no matter how much they take. It has a limited, ceiling effect, as oppossed to all the standard narcotics.

    3) Patients on Suboxone feel “normal.” This is the term patients use spontaneously at clinic. They are not high, cognitively impaired, or lethargic with maintenance therapy. They are simply restored.

    4) Patients taking Suboxone cannot take a standard narcotic (as listed above) and receive any effect whatsoever from that drug. They can’t abuse their former drugs at all. Suboxone thoroughly “blocks” all of these drugs.

    5) Patients cannot relapse (!) to narcotic abuse if they stay on their daily Suboxone.

    6) Suboxone patients can lead normal, productive lives with the standard monthly clinic visits versus the standard daily clinic visits of methadone maintenance.

    I will note that, utilized as an outpatient medication, Suboxone can be diverted by a minority of patients. Clinicians are acutely aware of this. There are several strategies that are used to detect and thwart this. More effective strategies, including more sophisticated use of laboratory tests, are under development.

    We simply cannot throw out the wheat (healthy patients) with the minority of chaff (scheming diverters.) This therapy must be available to patients who seriously want to regain their lost lives. They are wonderful people.

    Richard Bennett, M.D.

  5. Robin Robinette / June 19, 2014 at 5:17 pm

    We wouldn’t need to increase access to buprenorphine if we increase access to methadone. The barriers to methadone treatment FAR exceed those to buprenorphine, and since we have OVER 50 years of success with methadone, which is far less expensive, let’s mandate its
    coverage by all insurance carriers and require states to have x number of clinics, based on population? States with poor access to methadone treatment already have “buprenorphine mills” where the treatment is so expensive and doctors so generous that patients get more than they need and sell the rest to pay for the exorbitant office fee and prescription!
    I’ve been watching this prescription opioid epidemic evolve over the last 30 years in the South, and warning about it for 20! States like Tennessee keep the money flowing into the dysfunctional system while families are torn apart and people are needlessly dying, when cost effective and truly effective treatment is kept out.

    • Sue Carroll / June 21, 2014 at 10:08 am

      So, I am reading this.. I have a daughter (25) who is not an addict, she has a tolerance. She has had chronic pain most of her life. (never took anything for it, just has never been able to work or function like a regular human being) until. 2 years ago she decided to get a look inside to see what is up.. It took 2 years before that surgery was approved. During that 2 years her doctors got her started on Vic/oxy and then just cut her off, cold tureky. Her own doctors refused to give her any more pain meds because her tolerance kept getting higher (yet they would not do the surgery) so we found a pain doctor who then wrote her up to 400 10-mg oxy every month!! She didn’t ask for this to happen… The first docs who wrote her the pain meds made this happen.. She didn’t buy them on the street; then they just cut her off so she found a way to deal with her pain.. Finally she had her surgery and they didn’t find the cause, but she could no longer afford her pain doctor at 150.00 a visit, so what now? She has only gotten a script for 5/325 mg when she got her teeth pulled (#14) oh yea, that helped.. So now, she suffers, and every time she does need some help (like a kidney stone) docs tell her she is a drug seeker.. She asked the last doc how he can go to sleep at night treating patients like this.. How bout those docs who did this to her? Now, she tries to get buy with a few Ultram a day from a friend of hers, gabapentin and weed (Colorado legal), and she “gets by” but she cannot even get a job because she has so much pain…all she wants to do is function, and she would prefer to function w/o narcotics, so what is the answer to this? On an end note, let me just say, 5 years ago this month, my then 73-year-old dad put a gun to his head and shot himself because he could not get away from his pain.. and he was on Vicodin, but it didn’t do enough to keep him from dying.. So what is the answer? I am begging my girl to try Suboxone, but don’t know if she will consider it or even if she could afford it.. There simply has to be an answer, and making people with chronic pain just suffer until the put a gun in their mouth is certainly not the answer..

    • Sue Carroll / June 21, 2014 at 10:10 am

      Methadone can have very severe side effects called “tardive dyskinesia” which can stay with you for life if it happens to you, hence, methadone is not an option for a lot of people.. Google it..Not pretty and not acceptable.

  6. Rick Campana / June 19, 2014 at 4:07 pm

    I agree w Dr Sviokla. Limiting prescribers who are Board certified in addiction medicine is extremely short sighted and limits access to those doctors best suited for treating these patients. I agree that limits should be placed on MDs wo addiction medicine experience, especially wo certification by ABAM.

    • jaclyn / June 20, 2014 at 3:02 pm

      I don’t know about your state, but methadone is FAR more expensive in NJ than suboxone is.

  7. The epidemic has clearly worsened in our community, and the MD’s who prescribe are essentially all maxed out. The vast majority of providers are very responsible prescribers. The incidence of heroin and other opiate overdoses will surely be reduced in our community by improved access to buprenorphine services. The limits should definitely be raised.

    • Chris / June 20, 2014 at 2:30 pm

      The reason the doctors are getting so overwhelmed with clients is because addicts are excited. It’s now legal for someone to get an Opioid like high. Think about how awesome this would be for an addict. You don’t ever have to look for drugs again, you don’t ever have to worry about being shot to get drugs and you never have to worry about getting a bad product. Who wouldn’t want this drug. I am a Recovering addict of 13 years and it’s got me thinking about going and getting it. This way I never have to deal with a craving again, never have to worry that if I do something I will get into trouble and I never have to worry about dealing with another shady drug dealer. YAAAAA!!! sign me up right now.

      • TiTi B / June 25, 2014 at 2:46 pm

        I was a heroin addict and the thought of suboxene did not appeal to me. There was not comparison of it to the high I got from shooting dope. I do not agree that “addicts” are excited. Believe me, suboxene was not something exciting for me. If you really want proof, go try to get a prescription for it. Then post something.

      • WMK108 / July 2, 2014 at 3:56 am

        Chris,

        Congrats on 13 years clean! You seem very angry though, you really should let that go, it will literally eat you up! It may help to know that no one is getting ‘high’ off buprenorphine! Oh sure maybe the first couple doses, but not beyond that there is no ‘high’ or euphoric feeling. People maintained on this function normally and you would NEVER be able to tell they are prescribed anything. You can’t ‘take more’ buprenorphine to get a ‘better’ feeling, like some people say you can do with methadone.I am 7 years clean. Although,depending how you look at it, some don’t consider me ‘clean’ due to being on buprenorphine. I know where my life was and where I am today, and I consider myself ‘clean’. I am now at a point where my life has changed so DRASTICALLY that I am confident I can cope without the buprenorphine. That is the thing, as addicts we lose SO much (all of our own doing, of course) and have so many things we need to deal with in our recovery, especially early recovery! The relapse rate is outrageous, especially for opiate addicts, the deck is stacked against us from the start. Buprenorphine is a ‘tool’ that takes away the craving, like you said, but does not get you ‘high’. That is EVERYTHING an opiate addict needs in early recovery. If it got you ‘high’, yes. it could be considered a substitute. Instead, it takes away the NEED, leaving us with the ability to focus on rebuilding our lives and focus on the details of our recovery. I know for me, ‘feeling’ high would not have aloud me to move beyond obsessing about BEING high… that doesn’t seem like a good formula to me. Like the other commenter said, if you think it gets you ‘high’, just try it for yourself…But after 13 years, you have made it this far, keep doing what you are doing. Then again if it ever comes down to caving to your cravings and staying clean, buprenorphine will ALWAYS be the better choice. As an addict it has always bothered me to see the superiority some ‘clean’ people over others – we are ALL capable of slipping, NONE of us are above relapse! You have no idea where others have been or where you are going. You never know, as much as I sincerely hope and pray you never need buprenorphine, you really just never know! I wish you the best of luck.

  8. Katherine Fornili, MPH, RN, CARN / June 19, 2014 at 2:50 pm

    One clear cut strategy for improving patient access to buprenorphine products would be to amend DATA 2000 to enable office-based opioid treatment (OBOT) by psychiatric/mental health nurse practitioners who have the authority to prescribe scheduled medications under their respective states’ Nurse Practice Acts (Fornili & Burda, 2009; Roose, Kunins, Sohler, Elam & Cunningham, 2008; Fornili & Burda-Cohee, 2006).

    This prohibition against nurse practitioner buprenorphine prescribing inhibits the expansion of opioid treatment, and restricts access to medication-assisted treatment by individuals with opioid addiction.

    Office-based physicians have shown slow and low rates of adoption of pharmacologic interventions for addiction (Doescher & Saver, 2000; Olsen, Bass, & McCaul, &
    Steinwachs, 2004; Thomas, Wallack, Lee, McCarthy, & Swift, 2003, Fornili & Burda, 2009); and “the number of individuals receiving pharmacotherapy continues to be small relative to the large number with substance use disorders” that could benefit from treatment (Mark, Kassed,Vandivort-Warren, Levit&Kranzler, 2008).

    Advanced practice nurses have some degree of prescriptive authority in all 50 states and the District of Columbia. In 40 states, they have differing authorities to prescribe schedule II–V
    controlled substances, and in 8 states they can prescribe only schedule III–V drugs, and only 3 states do not allow advanced practice nurses to prescribe controlled substances (Berry &
    Dahl, 2007).

    “Buprenorphine is one of the few medications that only physicians can prescribe, although the rationale behind this policy is not clear . . . NPs and PAs are interested in expanding their role to treating opioid dependence. . . . The implications of allowing NPs and PAs to prescribe the drug should be explored given the low numbers of opioid-dependent patients who receive treatment” (Roose et al., 2008).

    Some opposition to nurse practitioner (NP) prescribing of buprenorphine may be related to unfounded concerns about NP levels of expertise. According to the Baltimore Sun in an article about the role of nurse practitioners in health care reform and their importance in terms of cutting costs and keeping people healthier, “some physicians say nurse practitioners don’t have the expertise to handle the load” (Brewington, 2009, p. 14). The evidence suggests otherwise.

    Linda Pearson, DNSc, APRN-BC, FPMHNP, FAANP has examined absolute numbers of accumulated occurrences of malpractice claims and adverse actions against NPs, DOs and MDs over 19 years, and calculated national occurrence ratios by dividing the total number of each group of providers by the total number of occurrences against that group. The number of malpractice and adverse actions were 1 in 173 for NPs, and 1 in 4 for DOs and MDs. Further, the ratios for accumulated adverse actions reports, civil judgments and criminal conviction reports were 1 in 226 for NPs, 1 in 13 for DOs and 1 in 23 for MDs (Pearson, 2009).

    Legislators need to understand how prohibition of buprenorphine prescribing by non-physicians restricts opioid-dependent individuals’ access to potentially life-saving treatment.

  9. jaclyn / June 19, 2014 at 1:38 pm

    So here is my issue. Maybe it is because I live in a rural area, but the issues are not finding a doctor to prescribe. The issue in NJ is that in order to even walk through the door to SEE the doctor who prescribes subs costs any where from $150-$350 A MONTH! People cant afford that! At least insurances cover the medication itself, but if you cant afford the appointment to get the meds then what’s the point of the insurance COVERING THE SCRIPT? If I had bi-polar that needed to be treatment no one would tell me it is going to cost me that much money to see my doctor just to get a script for the meds I NEED to stay healthy. But they feel that it is ok to do this to people with the disease of addiction? Its unfair and unjust. If insurance covers the medication it should cover the appointment to get the medication. Im A CADC in this state and I see the struggles. Its some real stuff. These people cant afford that type of treatment. Even methadone isn’t funded by the state and what slots are funded are limited. It costs $80 a week just for methadone! It still comes out to over $300 a month! These people have a DISEASE that needs to be treated. Im tired of the wrap people in recovery get for trying to do the RIGHT thing when they system just pushes them right back down. Its a set up for failure if you ask me. The meds are there but they aren’t accessible due to people not being able to afford the appointment-not the meds. Something is very very wrong with that if you ask me.

  10. Chris / June 19, 2014 at 12:55 pm

    I disagree with all of this. I am an addictions professional and I see the impact of this drug first hand. All people are doing is becoming addicted to another drug. Suboxone gives people the false hope that they are cured. When they get off the drug they suffer horrible withdrawal and most of the time go straight back to their addiction to relieve the pain. All this is doing is making the Opioid buzz legal and assessable just like the medical Marijuana card. If you want to stop Heroin and pain killer addiction then treat the persons symptoms, don’t give them another drug to become hooked on. None of the clients I have had that were prescribed this were ever serious about sobriety and all thought they were cured because they were on it. This drug just covers up the problem and then when they get off it they don’t know how to stay sober because they were never sober in the first place. All this is doing is making more money for the pharmaceutical companies.

    • Rick campana / June 20, 2014 at 9:22 am

      Chris, with total respect for your opinion, i strongly disagree with your assessment that offering Buprenorphine is trading one addiction for another. I am a board certified addiction specialist who has been providing MAT (Suboxone) therapy for over 11 years. This medication has allowed opioid addicted patients to regain their lives, be gainfully employed, have healthy relationships and to remain in meaningful recovery.

      • Chris / June 20, 2014 at 11:07 am

        While being addicted to another drug right? Let me ask you a question Rick. If these people stop taking this medication do they go through withdrawal? If so then obviously they are addicted to it right? I was addicted to drugs for over 13 years and the only way I was able to become sober was to deal with my issues, not cover them up with another drug. I deal with people constantly trying to get off of Subs and they all say that the withdrawal is horrible. Maybe you should take the medication for a year and try and come off it and tell me how you feel. I don’t mean to be rude it’s just that doctors cannot relate, they just agree with whatever their told. I understand that society is frustrated with trying to help people with drug issues, but giving addicts another drug to become addicted to is ridiculous. Take this example for instance. I know it sounds a bit immature, but just think with me for a moment. What if something happened in this country like we were attacked and couldn’t get to a pharmacy to get our meds. The poor souls are going to have to suffer through the horrible, sometime 2-3 month withdrawal from Suboxone before they can even think about protecting their families. At least Heroin and Opioid withdrawal only last a few days. I have heard that the withdrawal from Subs can last a few months. Tell me this isn’t ridiculous.

        • jaclyn / June 20, 2014 at 3:12 pm

          no more ridiculous than me having a script for Xanax and going through withdraw because I am being treated for anxiety and PPD. Like I said, it works for some people. May not be for you, but don’t knock the people who do take it. Who are you to judge and tell them what to do anyway? I mean Im just being honest

    • jaclyn / June 20, 2014 at 3:08 pm

      Chris, I am also a professional in the field and state licensed to treat and I respectfully disagree. My HUSBAND is on suboxone and it has saved his life. It has allowed him to stay clean for years while building his skills. Hopefully one day he wont need the subs, but if he does so be it. Its safer for not only himself, but for our FAMILY. As an addict in recovery you of all people should know that you are not the only one who is affected by not only your addiction, but your recovery as well. It has to be right for the family. not just the individual. As a counselor, I would think you would be more open minded to MAT as it saves lives even if not your own.

      • Chris / June 20, 2014 at 4:53 pm

        I am a counselor and that is why I hate Suboxone with a passion. Anytime someone gets off of the medication they almost always lack the skills to stay sober because they haven’t had the opportunity to go through life without a crutch like Suboxone. I hear “this medication levels me out” all the time. So when they get off it they are all over the place. Suboxone is a temporary fix for a permanent problem. The only way to truly be sober (which people who are prescribed Suboxone are not) is to be abstinent from all drugs, period. The Xanax withdrawal only last a few days. Do some research about how long the Suboxone withdrawal last. This drug is a joke and I am not a supporter of it and I will never be a supporter of it. I am not knocking the people who take the medication I am knocking the medication and the people who are selling this crap. I have love and compassion for all addicts that is why I care. This medication is only there to make the pharmaceutical companies money.

        • Jan Widerman DO / June 21, 2014 at 12:41 pm

          Chris Your statements do not support the knowledge of addiction as a chronic medical problem that needs both physical and mental treatments. My frustration with treating patients is the counseling “experts” voicing their opinions not based in science. Please review the report from Columbia June 2012 before you continue to express your thoughts. Of course Suboxone cannot be stopped abruptly. 1 mg is occupying close to 40% of the receptors. That is why it is prescribed professionals.

    • Avatar of Rhonda
      Rhonda / June 22, 2014 at 8:51 am

      Chris. I disagree with you. I have been on methadone for a few years. I was on 90 mil daily. I use methadone as a stepping stone to be clean. I have been detoxing myself my going down 2 mil a week. I am now on 11 mil a day. I have been great and methadone really helped me. The only bad thing is that its not covered on my insurance. The sad thing is, everyone on Medicaid gets it FREE because the state pays for it. I pay $60 a week and watch others on Medicaid get it handed to them free. The doctors at methadone clinics seem to only want to be in network with Medicaid for some reason …………. Good luck to everyone.

    • TiTi B / June 25, 2014 at 3:00 pm

      Chris, you addiction professional, it’s legal and “accessible”. Having access to – is that what you mean? You can get off suboxene by weaning down your milligrams. I have done so. It does take time however, it is possible. I attend AA and see a therapist on a regular basis. My sponsor and my support group were very helpful to me through this process. I can tell you that everyone is different and their systems react differently when getting off of a medication. That being said, if you want to get off of something bad enough, as I did, you WILL get through it. I still feel that suboxene helped me until I didn’t feel I needed it anymore. A lot of faith and prayer didn’t hurt either!

  11. Skip Sviokla MD ABAM / June 19, 2014 at 12:07 pm

    I am confused about Dr. Volkow’s stated reasoning that buprenorphine overdoses in Europe provide a salient reason to maintain limits on qualified prescribers. I respectfully disagree with her position.
    Skip Sviokla MD ABAM
    author, “From Harvard to Hell and …back”

    • Alison Knopf / June 19, 2014 at 12:13 pm

      Buprenorphine is prescribed for pain in Europe and therefore much less controlled, hence the overdoses and Dr. Volkow’s concerns about a backlash if there are overdoses here.

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