Policy Plenary Opens Debate on Buprenorphine Prescribing Limit

Countering all the positive outcomes of buprenorphine treatment for patients with addiction are the negatives of the drug’s misuse that are frequently cited by critics, including legislators who oppose expanded use of pharmacotherapies to treat addiction. Saturday’s ASAM Policy Plenary opened the door to a passionate discussion of how to address the problem.

D3-Buprenorphine Panel

(From left) H. Westley Clark, MD, JD, MPH, CAS, FASAM; Scott A. Teitelbaum, MD, FAAP, FASAM; and Mark Kraus, MD, FASAM.

The session, “Consequence of Changing the Buprenorphine Prescribing Limit,” featured H. Westley Clark, MD, JD, MPH, CAS, FASAM, reviewing facts about buprenorphine use and misuse. Then, he and session moderators Scott A. Teitelbaum, MD, FAAP, FASAM, and Mark Kraus, MD, FASAM, opened the floor to discussion from attendees, but the session ended with about a dozen people still lined up at microphones waiting to speak.

Opinions ranged from those supporting physicians being allowed to prescribe buprenorphine beyond the 100-patient limit, to those who questioned a need for that expansion, to suggestions for other options. Two themes often cited by speakers were to remember the patients and to remember what caused concerns about drug misuse.

“From my perspective, it is premature to be discussing the issue of caps. Maybe we should be talking about the quality of care,” said Dr. Clark, the former Director of the Center for Substance Abuse Treatment, part of the Substance Abuse and Mental Health Services Administration. He is now the Dean’s Executive Professor of the Public Health Sciences Program at Santa Clara University.

Dr. Teitelbaum, Professor and Vice Chair, Department of Psychiatry, at the University of Florida, also reminded everyone, “You better pay attention to the opposition and what they are saying. People are trying to do the right thing, and the reality is there is a problem out there.”

D3-Buprenorphine Crowd

Mark R. Publicker, MD, FASAM, makes a comment during the session, as other attendees line up behind him to speak.

Audience member Michelle Lofwall, MD, University of Kentucky, Lexington, said she had concerns about the lack of physicians in rural areas who had obtained waivers to prescribe buprenorphine, and suggested a compromise to the 100-patient limit.

“Maybe we need a more nuanced approach,” she said. “If we had someone at the limit, let them increase that limit when they are in a dire situation. Maybe we should be tweaking the approach.”

ASAM President-Elect R. Jeffrey Goldsmith, MD, DLFAPA, FASAM, speaking from the audience, discussed the broad patient population he has treated at a VA hospital. When it was suggested that more physicians could prescribe buprenorphine after taking ASAM’s eight-hour course, he said that was not the solution.

“I think we need to get out of narrow-minded thinking. It is not just the prescription,” he said. “People avoid going to treatment. There is a complicated set of problems. You have to appreciate the complexity of the situation and deal with it.”

Following a discussion of the time required to adequately diagnose and treat a patient, Dr. Clark offered a comment repeated during the session: “We want to make sure we don’t become the next pill mill.”

Other comments from audience members:

  • “I have concerns about lifting the limit. I work in inpatient care, and I would have trouble treating more than 100 people.”
  • “We would have fewer deaths if we could increase the numbers. Every time I prescribe, I am taking somebody away from a dealer.”
  • “Legislators listen to us, but they also listen to our patients. We need to look beyond our walls and partner (with patient groups).”