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Why Physicians Are Reluctant to Wade into the Addiction Treatment Fray

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Buprenorphine holds the promise to cut the opioid addiction in half. Why are only five percent of clinicians prescribing it?

The New York Times lays out the problem succinctly:

  1. FDA-approved Buprenorphine reduces the death rate from opioid addition in half. 
  2. Only about one-third of all U.S. treatment facilities provide the drug.

What is happening here?

This article explores a number of reasons that physicians have been somewhat reluctant to obtain the necessary waivers required to prescribe buprenorphine as an addiction treatment. What challenges do they face? What can be done to overcome them?

Skipping Addiction Treatment

The Substance Abuse and Mental Health Services Administration (SAMHSA) points out that buprenorphine can be prescribed in an outpatient setting, unlike methadone. In theory, this will improve patient access to treatment across any family practice. All doctors or mid-level providers have to do is apply for the buprenorphine waiver. Studies suggest that this type of outpatient treatment is not only more effective at halting the terrible effects of opioid addiction, it is a much more cost-effective alternative to treating patients in an inpatient rehabilitation center.

Yet MedPage Today says only five percent of American physicians have applied for the waiver. A New York Times op-ed suggests, This widespread rejection of proven addiction medications is the single biggest obstacle to ending the overdose epidemic.” 

Buprenorphine is prescribed in regular doses that eliminate the high felt from opioids. When taken regularly, it offers a physical dependence that is not an addiction; these patients are able to regain their health and function normally in society. In fact, it is no different from any other patient receiving a maintenance dose of medication; consider buprenorphine similar to an insulin shot or a beta-blocker. 

Addiction treatment

A maintenance dose of buprenorphine is no different from a beta-blocker or an insulin shot — or is it?

Buprenorphine does not “replace one addiction for another,” yet this judgmental myth persists even in healthcare communities. This fuels the reluctance physicians feel about prescribing these medications. With that said, some of these same physicians may have no problems with prescribing an opioid for pain relief. The MedPage Today article quoted a physician defining the stigma that substance users face in the medical community:

"My obese patients who have diabetes and heart disease are addicted to food. My alcoholic patients with cirrhosis are addicted to alcohol. Why should it be any different for me to treat opioid addiction than it is to treat all the other addictions that family doctors and internists deal with all the time?"

While the unconscious stigma attached to substance use is clearly alive and well in some medical circles, other physicians may feel that the additional federal oversight and scrutiny that comes with the buprenorphine waiver is simply not worth prescribing it for addiction treatment. 

Since this is a relatively new treatment, some clinical providers within a large healthcare or treatment facility may not feel comfortable pioneering this treatment, particularly in light of the stigma surrounding addiction. 

Too, it is important to note that physicians simply may not understand addiction treatment. They are given woefully little training in this area in general practice. It is even possible that the clinical provider may not be aware of the efficacy of buprenorphine as a treatment modality.

No matter the issue behind the reluctance to prescribe, it is clear that more needs to be done to encourage clinical providers to use all of the tools at their disposal – including buprenorphine – to help win this fight.

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