Addiction Specialists Confront Obstacles to Providing Treatment

August 2006, Vol. XXIII, No. 9

The intersection of addiction treatment and social policy was examined in several symposia at the 37th annual Medical-Scientific Conference of the American Society of Addiction Medicine (ASAM), held in San Diego from May 3 to 7.

A plenary program on social policy considered the 30-patient limit for officebased buprenorphine (Suboxone, Subutex) treatment of narcotic addiction in the Drug Addictions Treatment Act of 2000. Mark Kraus, MD, chair of the ASAM Committee on Public Policy, declared the rule “arbitrary and capricious” and contrary to the intent of the Act, which is to foster new treatment access for opioid-dependent patients.

“It arbitrarily carves out a group for treatment, necessarily depriving others equally in need . . . and this constitutes de facto rationing of care without any basis,” Kraus asserted.

Kraus argued that addiction specialists should not be treated differently from other specialists by limiting the number of their patients, and that buprenorphine should not be distinct from other FDA-approved medications in the number of patients for whom it can be prescribed.

Denise Curry, deputy director, Office of Diversion Control, Drug Enforcement Administration (DEA), explained that while the DEA had no input on the 30- patient rule, it now has responsibility to enforce the limit, and the requirement that practitioners maintain documentation of their buprenorphine prescribing and dispensing, as current law.

Curry indicated, however, that the DEA conducts a relatively low level of surveillance of buprenorphine programs, with each of its 85 “diversion groups” inspecting only one practitioner per year of the 5256 currently certified to prescribe buprenorphine for opioid addiction. While diversion of buprenorphine from therapeutic programs to street use is of theoretical concern, Curry indicated that they principally find administrative problems involving inadequate record keeping. When encountering practitioners who exceed the 30-patient limit, the DEA has preferred to advise and to negotiate compliance rather than employ harsher enforcement, according to Curry.

“We have bigger fish to fry than a . . . practitioner who exceeds his 30-patient limit by 5 or 10 patients,” Curry said.

The conciliatory tone and apparently cooperative stance taken by the DEA did not appear to appease Krause. “Government's foray into this area of medicine has created more problems and more issues,” he remarked. “If government's major purpose was to prevent diversion, rationing of care is not reasonably related to that goal.”

Wesley Clark, MD, JD, MPH, director, Center for Substance Abuse Treatment (CSAT), advised that the 30-patient limit is currently under legislative review. The pending Senate bill 2560 to reauthorize funding for the “Drug Czar's” Office of National Drug Control Policy contains a revision of the 30-patient rule, which would allow practitioners to exceed this number after providing a buprenorphine program for 1 year.

Clark noted, however, that the CSAT has identified physicians who have become “overzealous” in prescribing buprenorphine. “Our fear is that with people being overzealous, we will have some diversion into naive communities . . . [resulting in] people who are principally dependent on buprenorphine,” he said.

Although the medication has proved effective in satisfying opioid dependence without disrupting psychotropic effects, Clark cautioned that “street pharmacologists” are likely to try it in various combinations to enhance its euphoric effect and abuse potential.

“While we're not trying to restrict people's practice or income, we hope that practitioners will be reasonable in providing care,” Clark said. If the revised rule passes, he indicated, “a person can see as many people as they want . . . until, of course, somebody abuses the process; killing the goose that lays the golden egg, if you will.”

In the open discussion from the floor, Jim Berry, MD, of Bangor, Maine, declared, “The 30-patient limit discriminates against patients in rural areas.”

There are already too few practitioners in these regions, Berry explained, and even fewer who wish to provide addiction treatment. “I would plead with you that even if you can't do away with the 30-patient limit, that you try to address this rural-urban discrepancy and treatment availability,” he said.

Recognizing the rural problem

The particular challenges of providing addiction treatment in rural areas were the subject of another symposium. Several speakers began with slides of picturesque small towns and the bucolic settings in which they practiced, proceeded to describe the regions' disproportionately high rate of substance abuse and the absence of nearby treatment facilities.

Art Van Zee, MD, of St Charles, Virginia, admitted to not having had much interest in treating addicted patients in the small coal mining town until the late 1990s, when it was “taken over” by an epidemic of oxycodone (OxyContin) abuse. In 1997, he reported, the closest detoxification facility, about a 11/2- hour drive away in Lebanon, Virginia, experienced a 3-fold increase in admissions for opioid dependence.

“What we saw with the advent of OxyContin was a real tsunami of opioid addiction that had been unprecedented in the region,” Van Zee reported

Berton Toews, MD, of Casper, Wyoming, described his community's methamphetamine plight and noted data indicating that the likelihood of Wyoming high school students trying “street” and non-prescribed stimulants is several times higher than the national average. On the positive side, he pointed out that the relatively small population of the community and state has provided opportunities for constructive action.

“Wyoming is a small enough state that we're able to make changes at the grassroots level,” he said.

An “Addiction Providers Group,” was formed in Casper by practitioners in the community hospital and in private and public clinics. The group has adopted use of an addiction severity index and patient placement assessment instrument; successfully lobbied for an intensive outpatient misdemeanor drug court; and promoted plans for felony-level drug court that could sentence offenders to time in a residential therapeutic community.

Toews described pending grants for a “return-to-work” pilot project for employed methamphetamine addicts, in which the employer “plays the role of probation officer” by retaining the employee subject to continued negative urine screens.

“You don't need to leave them [patients] in residential treatment long enough to force them to lose their jobs,” Toews commented.

Robert Risinger, MD, of the department department of psychiatry and behavioral medicine at the Medical College of Wisconsin in Milwaukee, addressed the unique ethical problems of rural practitioners who care for patients with stigmatized conditions and who are also their neighbors.

“Rural clinicians have a really Promethean task in carrying, seemingly, every town secret,” Risinger said.

The rural practitioner faces the dilemmas of limited treatment resources for patients and “overlapping responsibilities and relationships with the people he provides care for,” he noted.

Risinger recommended that rural practitioners pay particular attention to privacy, such as by separating and securing office records of patients with mental health and substance abuse disorders from those with other medical conditions, to improve the willingness of patients to access care.

Risinger agreed with Toews, however, in seeing opportunities in the strong community ties of rural practitioners. “Providers in the rural care setting can exert tremendous influence within their entire communities; indeed, within their entire states,” he said. “I think the rural provider can actually be an engineer of social change; and is probably better equipped [to do so] in the rural setting than in the urban setting.”

Addressing health care disparities

Disparities in health care occur not only between urban and rural settings, but also between many other groups and environments, according to speakers at a symposium moderated by Lawrence Brown, Jr, MD, MPH, the immediate past president of ASAM. He was joined by John Nelson, MD, the immediate past president of the American Medical Association (AMA).

Brown attributed disparities in health care, education, and employment, in part, to the failure of society to embrace diversity, resulting in stigma, intolerance, and isolation. “What can we as individual physicians do to respond to this health care emergency?” Brown posed.

An initial action, Nelson suggested, would be for physicians to become more “culturally competent” in order to reduce barriers in the patient-physician relationship. Nelson recommended the Department of Health and Human Services Web site, thinkculturalhealth.org; and urged medical schools to incorporate materials like those on this site into their curricula.

Another symposium, addressing the disparities between the development and the provision of effective treatments, was structured so that the practitioners in attendance could work in groups to identify problems and recommend actions. The symposium panelists were contributors to the most recent Institute of Medicine (IOM) report in its Quality Chasm Series, Improving the Quality of Health Care for Mental and Substance Use Conditions. They summarized the report, emphasizing the tenet of patient-centered care, and then charged symposium participants to identify actions that would increase this orientation in their own practices.

• Include the patient's expectations, timeline, and intended level of abstinence in treatment plans.

• Avoid labeling patient as “in denial,” particularly as a basis to exclude the patient from treatment; provide treatment and support at whatever level can be assimilated.

• Increase the use of self-report inventories to better identify patient characteristics and conditions, and increase cognitive screening to better ascertain patients' capabilities.

• Increase transparency of the treatments and medical records for the patient.

The symposium organizer, Jeffrey Samet, MD, MA, MPH, of Boston University School of Medicine, complimented the participants for confronting the myth that mental health and substance abuse patients have insufficient capacity for decision making to benefit from patient-centered health care. He indicated his hope for a general understanding in the future that, “improving care delivery and outcome for either mental, substance use, or general health conditions depends on improving care and outcomes for the other 2.”

This is the first of 2 articles on the 2006 ASAM Medical-Scientific Conference; the second will report on treatment strategies.