Treating opioid addiction may get a bit easier

Washington -- Physicians considering adding treatment for opioid addiction to their practices may take comfort in knowing that a team of 45 mentors is prepared to offer them help and encouragement.

In addition, President George W. Bush signed into law Aug. 2 a measure lifting the cap on the number of patients a facility can treat -- a move that will allow many more patients addicted to heroin or prescription medications containing opiates to be treated in physicians' offices.

The passage of legislation allowing such office-based treatment, and the approval three years ago of the medication buprenorphine, signaled the start of a new era in addiction treatment. For the first time, physicians could be certified to offer treatment in their offices rather than referring patients to often overcrowded and distant substance abuse clinics.

"Since the 1960s, treatment for addictions had been behind closed doors at traditional opioid treatment programs or methadone clinics," said Anton Bizzell, MD, medical officer at the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment.

That's changing. So far, nearly 6,000 physicians have been certified to prescribe buprenorphine (a Schedule III drug), said Dr. Bizzell. Certification requires taking an eight-hour course on the specifics of treating with this drug and applying to SAMHSA for a waiver from the Controlled Substances Act.

In an attempt to attract even more physicians, a Physician Clinical Support System has been established and funded by SAMHSA. The PCSS was designed by a number of medical groups, including the AMA and the American Academy of Family Physicians, as well as the major addiction treatment organizations.

An important part of the new system is a national network of physicians selected in July to serve as mentors to physicians just embarking on this new treatment venture. All mentors have expertise in treating patients with buprenorphine.

Primary care physicians, pain specialists, psychiatrists and other physicians whose prime specialty is not necessarily addiction medicine are expected to be the major users of this support system.

Mentors will be available via phone and e-mail, plus they will open their office doors to others interested in watching them at work.

One newly named mentor, Martin Doot, MD, a family physician in Des Plaines, Ill., was mentoring before this formal program began. Addiction medicine has been a part of his practice for 20 years, he noted.

"Many physicians have been through the eight-hour training and have gotten their waivers and were a little bit anxious about getting started with a new treatment, about taking on that first patient," said Dr. Doot.

However, the logistics of treating patients for opioid addictions are not that different from other medical treatments, said David A. Fiellin, MD, medical director of the PCSS and an associate professor of medicine at Yale University School of Medicine in New Haven, Conn.

"There is a perception that these patients, by virtue of their addiction, are more challenging, but the reality for myself and for a large number of practitioners is that the patients are very appreciative and respond very well to treatment."

A large part of the mentoring program will likely consist of helping physicians feel comfortable in both assessing and monitoring patients as they move toward recovery, said Dr. Fiellin.

"Unfortunately, physicians haven't had much training in making the diagnosis and putting together a treatment plan for patients who have addictive disorders," he said.

However there is a great need for doctors in this field. Some estimate there are as many as 3.5 million people who could benefit from treatment.

The Aug. 2 lifting of the cap of 30 patients per facility was applauded by Dr. Doot and others as another route to opening treatment to more addicts. The change will allow each physician at a facility to treat a maximum of 30 patients.

Dr. Doot, for example, is in a four-person multispecialty medical group, so the revised law means his practice can move from treating a maximum of 30 patients to a maximum of 120 patients at a time.

The treatment itself has also opened the door to a different subset of patients -- those who had previously had great difficulty staying in treatment. Such patients had often been marked as unmotivated, but it was more likely that they had such a difficult time tolerating withdrawal symptoms that they dropped out of treatment, said Dr. Doot. "What we've discovered with buprenorphine is that it helps people very early in treatment to feel more normal."