Volume 4, Issue 3

Right on, Dr. Junig!
Holly Hagle, PhD
IRETA/National SBIRT ATTC

The theme that we are responding to for this issue of The Bridge is the use of buprenorphine in general medical practice, a simple request for a complex topic.

Reacting to: “The legislation [Drug Addiction Treatment Act, DATA] was revolutionary within the relatively small world of addiction practice in that it had a distinct mechanism for the involvement of primary care physicians.”

My initial reaction was total agreement. Dr. Junig captures the emotion that was swirling around the addiction field in the year 2000 when the DATA legislation was passed. It did feel revolutionary. We were thrilled to be taken seriously by the medical profession at large, especially the holy grail of medicine, primary care practitioners. It seemed so clear at the time. Yet the implementation proved difficult, as the old saying goes “the best laid plans”....

We all know there has been a varied reaction in the “real-world” to this very same DATA legislation. In fact, addiction and this very topic made it into contemporary media like The New York Times.

So given all of this “hype” over pill mills and diversion, it is refreshing to have a balanced point of view from Dr. Junig as he reflects on how different the uptake of buprenorphine might have been, had it not had the DATA regulation restrictions. Dr. Junig is especially insightful when he states: “Without the regulations, buprenorphine would likely have become prescribed by primary care to a much greater extent, which would have saved the lives of many, many young people.”

As I progressed further into the interview I admired the fact that Dr. Junig took on the “overblown buprenorphine diversion issues”. I can’t state it as well as Dr. Junig does, when he states “Having more prescribers might have resulted in less non-prescribed use of buprenorphine.” Again, another complicated “real-world” outcome from the DATA legislation.

After all as Dr. Junig states, “Buprenorphine has a strong protective effect against death, whether taken by prescription or through diversion. Specifically, over 35,000 US overdose deaths occur annually in the absence of buprenorphine, compared to about 40 overdose deaths each year when buprenorphine is one of the drugs in the person’s system.”

I mean, this is a serious reflection, as overdose is PREVENTABLE and life is complex, people are complex, and we live complicated lives.

Reading this interview reminded me of a conversation I had with a very esteemed and reputable New England addiction treatment center CEO at a dinner meeting recently. He was telling me about a project that he is engaged in, a partnership with a primary care practice. As this addiction treatment center is a NIATx organization they use data to make decisions and for process improvement. He shared with me one excel spread sheet of about 100 (de-identified) patient data from the primary. Almost all of the patients on that spread sheet listed anxiety and depression as a co-occurring condition along with their presenting physical health condition. We don’t question the PCP’s authority to treat anxiety and depression; we don’t question how much or little training they have to treat these mental health conditions—yet PCPs are treating these conditions and the people who have them every day. As Dr. Junig states, “Surgeons are given the responsibility to decide, all by themselves, which organ to remove—but addiction doctors aren’t trusted to make decisions about counseling? No other medical specialty assumes such a high level of ignorance in their doctors!”

People want help, people need help. We should not punish people for displaying symptoms of their illness.

“The lack of ASAM support for these physicians and similar cases will have a chilling effect on physician attitudes toward treating opioid dependence”.

The good news is that this is all fixable, as Dr. Junig states, in response to the question: “Would there be any disadvantages if the current patient limit of 100 was eliminated altogether?”

“Many lives would be saved.”

For opioid agonist addicts, the primary result from buprenorphine abuse is inadvertent treatment!

 



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