Researchers from Baylor College of Medicine and the Veterans Affairs Medical Center in Houston, TX, concluded that the use and expansion of buprenorphine therapy should not be limited or hindered given the strong evidence of efficacy. Their review on whether “to expand or not to expand” buprenorphine prescribing is published in the Journal of Psychiatric Practice

Buprenorphine, a partial agonist at the mu-opioid receptor, exerts similar actions to other opioids but with less abuse potential and a more favorable safety profile. A lower risk of diversion and non-medical use is seen with buprenorphine compared to methadone, a longstanding treatment for opioid and heroin addiction. Because it is a Schedule III controlled substance, physicians must receive a Drug Enforcement Agency (DEA) waiver, complete special training, and fall within limits on the number of treated patients in order to prescribe in office-based settings. Experts estimate that about 53% of U.S. counties do not have any physicians with a DEA waiver to prescribe buprenorphine. 

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Doctors Xiaofan Li, Daryl Shorter, and Thomas Kosten proposed strategies to encourage buprenorphine use while maintaining quality of care and lowering the risk of diversion and abuse. Some methods included allowing prescribing by advanced nurse practitioners and physician assistants, as well as allowing more patients to be treated. They also highlighted the concern about the growing abuse of intravenous (IV) buprenorphine. 

“This real-world, almost paradoxical, phenomenon demonstrates the complexity inherent in the treatment of addictive disorders–a medication intended to treat substance use disorder that has its own abuse potential, upon gaining popularity and increased availability, will inevitably be explored by drug abusers for reward and reinforcement purposes.”

Some of their proposals to increase effective treatment with buprenorphine while lowering the risk of diversion and abuse include the following:

  • Additional support for physicians with high caseloads and other measures to help prescribers comply with guidelines.
  • Continuing medical education targeting improvements in office-based therapy for opioid abuse.
  • Policies and regulations promoting safe practice.
  • Financial incentives coupled with mandatory enforcement of essential components of safe practice.
  • More active pharmacy involvement, including supervised dispensing.
  • Identification of groups at high risk of intravenous buprenorphine abuse.

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