Program helps doctors who treat addictions

Washington -- Kent Diehl, MD, a family physician in Bismarck, N.D., was suspicious that some patients' requests for pain medication were actually an indication that they were addicted to the opiates prescribed. "I'm a family practitioner and I was getting tired of seeing addicts or people I thought were becoming addicted coming in and giving me a story about their shoulder pain or their back pain."

Now, Dr. Diehl can confront the problem head on after joining a federal program that allows him to treat drug addiction by prescribing buprenorphine, a controlled substance that blocks the effects of heroine and other opioids on the brain.

"You are treating the problem. They don't have back pain, they're addicted," Dr. Diehl said .

But there were some rocky moments when Dr. Diehl began. He turned to a local drug treatment program for advice. "I got help with setting limits, the consequences of behavior and relapse. That helped make all the difference," he said. "You can't deal with an addict on your own in a busy clinical practice."

The federal Substance Abuse and Mental Health Services Administration, which coordinates the buprenorphine program, has taken note of this need for help and advice and is creating a mentoring program to coach physicians through their early experiences in dealing with a new set of treatment issues.

SAMHSA is teaming with the American Society of Addiction Medicine to develop a national network of about 50 physician mentors who have expertise in treating addiction to opioids with buprenorphine.

"We know from past studies that primary care physicians have a difficult time recognizing abuse and addiction and talking to patients about it," said Robert Lubran, director of SAMHSA's division of pharmacologic therapies. "We also know there is a strong reluctance on the part of the general medical practitioner to take on treating a population that is potentially difficult."

Calling for more physicians

The mentors could also help physicians recognize which patients are using medications responsibly and which are addicted, said David Fiellin, MD, president of the addiction medicine society.

Dr. Fiellin, a Connecticut internist, wasn't surprised that primary care physicians didn't sign up for the new program in great numbers. "It has been clear to me from the beginning that physicians would need some form of assistance."

However, once enrolled, many physicians derive satisfaction from this new role. "There are few aspects of medicine in which I have seen such a profound change in patients over a very short time," said Dr. Fiellin.

So far, more than 3,000 physicians have taken the eight-hour training course and gained federal approval that allows them to prescribe buprenorphine to patients addicted to prescription narcotic pain medications or heroin.

But the need to have more physicians in the program is great. SAMHSA's National Survey on Drug Use and Health shows that almost 5% of people age 12 and older used narcotic pain medications for nonmedical purposes in the past year, said SAMHSA Administer Charles Curie. "Many users of these opioids will need to be treated for dependence or addiction," he noted.

SAMHSA's goal is to have 6,000 trained and approved physicians actively treating patients by the end of 2006, said Curie.

Meanwhile, the program itself could still use some alteration. Most policy-makers recognize that the cap of 30 patients per practice placed by the original law is constraining and, although the Senate approved a change in the law to lift the cap for group practices, the House failed to act on the measure before adjourning in October.