Many doctors don't prescribe medication for opioid addiction despite epidemic

Posted on: September 27th, 2016 by sobrietyresources

Dan Mangan | @_DanMangan

Tuesday, 20 Sep 2016 | 2:30 PM ET

This effective weapon in the fight against opioid addiction often isn’t being used.

A study released Tuesday found that doctors authorized to prescribe a drug that has shown success at curbing opioid cravings actually tend to prescribe the medication to significantly fewer patients than they potentially could — despite an ongoing painkiller overdose epidemic that kills more than 60 Americans every day.

CNBC separately has learned that fewer than 250 patients nationally have actually received a new long-acting implantable version of that drug, buprenorphine, in the two months since it has been available, even though more than 2,400 doctors have been trained in the implants.

“There seems to be, despite us being in the middle of a horrible epidemic, a missing sense of urgency in getting access for [addicted] people, and … opening up treatment pathways for people,” said Behshad Sheldon, CEO of Braeburn Pharmaceuticals, whose implantable product Probuphine was approved for use earlier this year.

The study findings and sales figures come as President Barack Obama designated this week as Prescription Opioid and Heroin Epidemic Awareness Week to focus attention on efforts to stem the rate of painkiller addiction and the resultant death toll, which has more than quadrupled since 1999.

During the time, buprenorphine, often sold under the brand name Suboxone, has become an increasingly popular tool to treat opioid addicts, by eliminating their withdrawal symptoms. About a quarter of the 2.8 million people or so people diagnosed with opioid abuse disorder take buprenorphine, typically in oral form.

But only about 2 percent of the nation’s doctors are authorized to prescribe the drug, and only about one-fifth of those waivered doctors write around 90 percent of all buprenorphine prescriptions.

The low rate of authorized doctors, and a 100-patient maximum cap on the number of patients an authorized doctor can treat, have been blamed for preventing wider use of buprenorphine, even in the face of evidence that opioid addicts are much less likely to relapse if they are placed on medication to manage their addiction.

In response to those concerns, the federal government this summer raised the maximum cap to 275 patients a single physician can treat with the drug. Since July, 1,275 practitioners have applied for and been approved for the new maximum, federal officials said Monday.

However, the Rand Corp. study released Tuesday suggested that even the doctors allowed to prescribe buprenorphine aren’t coming close to the number of patients they could be treating.

The study, published in the Journal of the American Medical Association, found that from 2010 to 2013 more than 20 percent of the doctors authorized to prescribe buprenorphine to opioid addicts were treating three or fewer patients with that drug. And fewer than 10 percent of such doctors were treating more than 75 patients.

The research also found that the median number of opioid addicted patients being treated by an authorized doctor with buprenorphine is often 11 or even fewer patients in 5 of the 7 states with the most physicians with such waivers. In California, the median number of patients was just seven for authorized doctors.

Those medians are well below the 30-patient cap that doctors initially faced when they were authorized to prescribe the medication. And it’s much lower than the 100-patient maximum that until this summer was the limit for doctors who applied for that new cap after holding a buprenorphine waiver for at least a year

“We were rather surprised to see such a large number of physicians treating relatively few patients,” said Dr. Bradley Stein, senior physician scientist at Rand, and senior author of the study. “We were really surprised that slightly more than 20 percent … are treating only three or fewer patients per month.”

“They certainly are not prescribing to what might be their capacity,” he said.

Stein said he and his fellow authors also were surprised by the study’s findings that the median duration for buprenorphine treatment per patient was just 53 days.

That was “lower than expected given clinical recommendations of maintenance treatment for up to 12 months and evidence linking longer treatments to better outcomes,” the study said.

Novice prescribers cited insufficient access to doctors with more experience prescribing buprenorphoine as well as “insufficient access to substance-abuse counseling for patients” as “barriers to treating more patients” in their own practice, Stein said.

He said that programs that offer mentoring to those doctors with less experience prescribing buprehnorphine and web-based or telephone counseling for patients might be ways to address those concerns, and increase prescription levels.

Sheldon, CEO of Braeburn Pharmaceuticals, said that when the company began offering the implantable form of buprenorphine for sale, “we expected, say, for the first month or so, that it would be be a really low number.”

But the 239 orders for Probuphine that have come in over the past two months are lower than even those expectations. And Sheldon noted that many of those orders have come from just two states, New York and California.

And “probably not even 10 percent” of the doctors who have been trained on implanting and removing Probuphine have ordered it, she said.

“There was an intensive and robust training program that you wouldn’t think people would go to unless they were going to prescribe the product,” Sheldon said.

Braeburn has hoped that Probuphine will be an attractive option for doctors who are concerned about patients giving or selling their burprenorpine to someone else, or who don’t want to argue with their patients about how much medication they should be receiving. The implant, which is placed in the upper arm, lasts six months, delivering a steady dosage of buprenorphine to the bloodstream.

Sheldon said that the relatively slow sales to date for Probuphine appear due to several factors, including doctors’ concerns about to what extent the implants will be covered by insurance companies.

“Some are being driven by waiting to see what reimbursement will be like,” Sheldon said.

Probuphine costs $4,950, compared to the $2,400 or so that buprenorphine strips would cost for the same six-month period, she said. But big insurers, both private and public, have been “very enthusiastic” about Probuphine and are willing to pay for it, she said.

“We actually have insurance companies calling us … they’re enthusiastic about a six-month implant that can’t be abused, misused or diverted,” Sheldon said. But it takes time for doctors to aware of that, according to Sheldon. “Until then, it’s our word they have to take.”

Despite the initially slow sales, Sheldon is optimistic Probuphine will become more popular. She noted that in addition to sales to physicians, Braeburn expects more business from institutions, who have expressed interest in the implants.

“It’ll be a little slow in the beginning, but then it will snowball and take off,” she predicted.

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