Quality & Science

Editorial Comment 2/16/2021: Prescriptive Discretion and Buprenorphine

by Editor-in-Chief: Dr. William Haning, MD, DFAPA, DFASAM | February 16, 2021

The final selection below addresses the recent effort on the part of the Department of Health and Human Services to remove specific training requirements for the prescription of buprenorphine, for physicians. As most will be aware, that plan has been suspended subject to further review, but remains alive.  The central focus of the article – actually an op-ed piece in The Hill - is on the distinction drawn between physicians and others with prescriptive authority (advanced practice registered nurses and physician assistants).  The CARA act of 2016 requires both classes of providers to undergo training in addition to that normally required for obtaining or maintaining a DEA license for the prescription of controlled substances. Presently, the training requirement is significantly greater (3-fold) for non-physicians.  The mandate was originally in recognition of the newer indication beyond analgesia for buprenorphine, for opioid use disorder.  It was as well a concession to those who contended that, without some form of interpersonal therapy, the medication alone was inadequate.

The authors’ objection to the two-tiered training requirements is based on the perception that “… the X-waiver requirement is a legal, codified manifestation of the stigma and discrimination people with opioid use disorder face daily.”  This may to some extent be true, but it is unbalanced. The use of buprenorphine, as with methadone, commonly carries a presumption of long-term administration and is conditioned upon abstinence from other drugs. And while details of the dosing, duration of medication, interactions and the like are best learned in a pharmacology curriculum in the providers’ schools, there really are some unique considerations for buprenorphine.

As have many prescribers, I have been called by otherwise really knowledgeable colleagues seeking advice in the timing of initiation of buprenorphine, the choice of the dose form, the management of aggravated withdrawal symptoms, and guidance for weaning the patient from potentially interactive sedative-hypnotics. In brief, there is sometimes more to this than an online course or a package insert can provide.  This has led to the establishment of both formal (e.g., Providers Clinical Support System or PCSS) and informal consultative resources (e.g., chat rooms) that go beyond simple FAQs.

I opted at this point in my commentary to stop, and to seek wider consultation. I should probably do more of this, particularly in policy arenas where there are so many overlapping views - regulatory, clinical, economic, guild, safety, just to start; and my own is hardly the final authority.  So, please have a look at the opinion piece, and we will return to it.

- Editor-in-Chief: Dr. William Haning, MD, DFAPA, DFASAM