Policy Plenary to Look at Buprenorphine Prescribing Limits

The increase in opioid addiction and overdose deaths has led to public officials looking for ways to reverse the trend. The ASAM Policy Plenary, “Consequence of Changing the Buprenorphine Prescribing Limit,” will discuss suggested options.

H. Westley Clark, MD, JD, MPH

H. Westley Clark, MD, JD, MPH

“There is an inadequate number of doctors prescribing buprenorphine, and therefore the argument that we should eliminate the cap does not address the problem that the issue of opioid misuse is much larger than the number of practitioners who are prescribing,” said the presenter at the session, H. Westley Clark, MD, JD, MPH, CAS, FASAM.

Dr. Clark was Director of the Center for Substance Abuse Treatment, part of the Substance Abuse and Mental Health Services Administration, when Congress passed legislation limiting the number of patients that physicians could treat with buprenorphine. Now the Dean’s Executive Professor of the Public Health Sciences Program at Santa Clara University, he has the experience and gravitas needed to discuss several issues related to buprenorphine prescribing limits during the plenary, presented from 8 to 9:30 am Saturday in Governor’s Ballroom A-C, Fourth Floor.

“I was with the government and we were responding to the field,” he said of the era when prescription limits were set. “One of the things we were tracking was not just the concerns clinicians were raising on the issue of limits, but also a countermovement on concerns about diversion and misuse of buprenorphine. No one has come up with a reasonable strategy to help address those issues.”

That countermovement continues, with some members of Congress coming out against the use of medication-assisted treatment in substance abuse, claiming it lacks adequate evidence of success, Dr. Clark said, adding that he will address some of those other concerns, including:

  • The lack of clear clinical goals and objectives being articulated to the public, as evidenced by a flurry of media coverage
  • Diversion of buprenorphine from treatment into street use
  • The pushback from public officials, including some in law enforcement, who believe recovery should only be drug-free and not include opioid-maintenance treatment
  • The CDC’s argument that opioids are bad for women of child-bearing age because of studies linking a twofold increase in neural tube defects to opioid use
  • Some state limitations on the dose and length of time a person can get Medicaid payments for buprenorphine
  • A few physicians who have been accused of price gouging or misbehavior with regard to buprenorphine
  • Other physicians who have been accused of ignoring psychosocial function in favor of simply dosing with buprenorphine

“Clearly on some of those issues I’m not going to take a pro/con position. I do believe the issue of buprenorphine treatment has been elevated in the political consciousness, with Representative Murphy coming out at his hearing, taking the position of being anti-medication-assisted treatment,” Dr. Clark said of Representative Tim Murphy (R-Pennsylvania), chair of the House Oversight and Investigations Subcommittee, which recently had a hearing on opiate and heroin addiction. “How far that opinion goes will be something addiction medicine specialists will have to deal with.

“This topic is front and center. We need to have a better idea of how we monitor and track, and the outcomes of our interventions because people are raising those concerns. We need to make it clear that if we are dealing with a chronic disease, that it is justifiable to use buprenorphine or methadone or naltrexone to help stabilize a person. We should think in terms of addressing psychosocial decrements of function, not just ideological phenomena.”