Volume 4, Issue 3

Some Challenges to Dr. Junig's Assertions
Ron Jackson, MSW
University of Washington School of Social Work

First a question to The Bridge editor: Why are you interviewing a psychiatrist about the use of buprenorphine in primary care physicians? Why not interview a primary care physician about her experience with and perspectives about the issues in the use of buprenorphine in the treatment of opioid use disorder in primary care practice? I honestly don’t believe that Dr. Junig has the perspective or experience to discuss this issue. So, my main recommendation is to find a primary care physician, not a psychiatrist, to answer your questions.

Second, in your first question you state that “The introduction to buprenorphine treatment in the U.S. has occurred through a controlled system somewhat parallel to controls on methadone.” The buprenorphine treatment system is in no way as regulated as is methadone treatment, which is constrained by federal and state rules and accreditation guidelines, none of which apply to office-based buprenorphine treatment.

Now to my reactions to Dr. Junig’s interview responses:

While I wholeheartedly agree with Dr. Junig on many of his points, specifically his advocacy for funding medication-assisted treatment as a chronic medical disease for which time-limited treatment should not apply and that indefinite maintenance on agonist or partial agonist medication in the treatment of opioid use disorders is a perfectly acceptable treatment pathway, I do take issue with some of his other assertions.

My main point of disagreement with Dr. Junig centers on his assertion that all buprenorphine diversion occurs because those in that illicit marketplace are seeking/purchasing diverted buprenorphine for their own self-medication, either to help their own-managed withdrawal from opioids or to serve as a bridge between periods of illicit opioid use. I’ve heard that argument, ironically, before, early in the 1970’s, about the diversion of methadone from opioid treatment programs.

It was untrue then. I’ve also heard this argument recently about buprenorphine, to which I always reply, “Where are your data to support that contention?” I think Dr. Junig is advancing a belief-based argument in order to support his expressed interest in eliminating the caseload capacity for buprenorphine-waivered physicians. I’d preferred to be informed by data about what percentage of buprenorphine diversion is attributable to the reasons Dr. Junig cites and what is attributable to individuals seeking buprenorphine in order to get high.

I’d like to have a better idea about that before making the sweeping policy change of eliminating the current 100 patient capacity limit because there are data that suggest that buprenorphine diversion increased when the 30 patient capacity limit was increased to 100 patients in 2006. Moreover, to take his assertion to its logical conclusion if, as Dr. Junig states “…if a person takes buprenorphine for any reason—even just to avoid withdrawal until a better batch of heroin comes to town—that person is less likely to die from overdose” why not at the very least make buprenorphine an unscheduled medication like naloxone or, at the extreme make, it an over-the counter medication? I can’t imagine a data-based argument that would support either of those positions.

About the issue of psychosocial counseling by physicians of patient on buprenorphine, I’d like to take issue with several of Dr. Junig’s assertions. First, when asked, “How successful have physicians been in linking buprenorphine patients with psychosocial counseling?” he replied, “successful enough.” I’m not even sure what “successful enough” means and I’d be curious to know not only how Dr. Junig defines the term he used as well as upon what data he bases this assertion. One of the shortcomings of DATA 2000 is, in my opinion, that it did not establish a mechanism for gathering data about the practices and outcomes of waivered physicians. Ideally, we’d have such data to compare and contrast who’s being treated by DATA-waivered physicians and how those outcomes compare with patients being treated in Opioid Treatment Programs, for which data do exist.

The other assertion with which I’d like to take issue involves his response to the question, “Simply on the basis of their skills as physicians, and assuming they were willing to spend the time, do you think the majority of physicians could successfully deliver this psychosocial counseling?” He did not address the issue of physician time and willingness to use the precious few minutes that primary care physicians have to spend with patients. Dr, Junig is a psychiatrist and probably has a great willingness to talk with and listen to patients and will structure his patient time to accomplish those tasks. In my work with primary care physicians about their time management as it relates to assessing and intervening with substance use disorders I constantly hear those physicians concerns about time pressure. So, despite, Dr. Junig’s assertion based on his practice, I think it’s an open question about primary care physicians’ willingness and time to deliver psychosocial counseling to their patients on buprenorphine.

And all of this goes directly to the question of an unlimited patient capacity for the treatment of patients with buprenorphine. First of all, I don’t think the data exist about how many of the physicians who have the 100 patient limit are actually at that limit. Are we really ready to have physicians with 300, 500, 600 patients on buprenorphine with all of the unknown questions about treatment outcomes, e.g., how, if at all, are outcomes affected by physician caseloads, and the potential risks for diversion? With all due respect to Dr. Junig, there’s no street market for albuterol or lisinopril, so his analogy to the treatment of asthma and hypertension isn’t exact.


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