Peer mentoring may be the best way to get more physicians to accept buprenorphine and treat opiate addicts in their office-based practices, according to researchers who spoke at Join Together's recent Demand Treatment: Lessons Learned Institute in Chicago, Ill.

Experts are enthusiastic about the drug's early success and its potential to ease the stigmatization of heroin users, as well as their addiction. "The availability of buprenorphine is going to be a big deal; it's going to make a big difference," predicted Richard Rawson, Ph.D., associate director of Integrated Substance Abuse Programs at UCLA, who contrasted an 80-percent dropout rate among heroin addicts in a study of drug-free outpatient programs to the 80-percent retention rate found in the National Institute on Drug Abuse's (NIDA's) human trials involving buprenorphine.

Despite the drug's promise, however, primary-care and family-practice physicians have been slow to integrate buprenorphine treatment into their practices, as permitted by the Drug Abuse Treatment Act (DATA) of 2002.

To date, about 4,500 doctors have received required buprenorphine training, 3,763 have submitted applications to allow them to prescribe the drug, and 3,305 certifications have been issued by the Drug Enforcement Administration.

But as Rawson noted, "Only about 60 percent of buprenorphine-certified doctors are actually using the drug in their practice." Moreover, the number of certified doctors represents a tiny fraction of the estimated 781,000 physicians in the U.S.

Martin Doot, M.D., medical director of the Advocate Addiction Treatment Program in Des Plaines, Ill., told the discouraging story of a doctor in an addiction clinic with 25 years experience, in personal recovery, who got his buprenorphine training and waiver. "Three months later, he gives me a call wanting to refer his first patient to me," recalled Doot, who agreed to initiate the patient on buprenorphine, then successfully coached the doctor through the process of maintaining his patient on the medication.

Doot is involved in the Physician Clinical Support System, a new buprenorphine mentoring program developed by the American Society of Addiction Medicine and the Substance Abuse and Mental Health Services Administration -- a unique project to support physicians treating opiate addiction with buprenorphine. The program, which aims to get 6,000 primary-care and family-practice doctors approved, trained, and actively treating opiate patients by the end of 2006, includes mentoring visits to doctors' offices as well as phone and e-mail support.

"Many -- if not most -- family doctors need more than the one-day training and certification in order to feel comfortable actually treating patients with buprenorphine," said Doot, who sees physician-to-physician mentoring as key to improving acceptance of the drug. "Family physicians learn by doing, not by just reading or listening."

A poorly written provision of the DATA act, which effectively limits group practices to treating just 30 buprenorphine patients at one time, also has slowed progress on mainstreaming the drug. (This month, the Senate approved legislation that would amend the law so that the 30-patient cap applies to each physician, not each practice. Similar legislation is pending in the House.) Many of the so-called "drug-free" treatment programs that oppose the use of methadone also have been reluctant to embrace buprenorphine.

"Buprenorphine therapy can get quashed because it's not in the formulary, pharmacists don't know about it, etc," added Doot. "The rest of the system needs to integrate buprenorphine."

Despite the problems, however, Doot and other researchers are optimistic that buprenorphine will eventually become integrated with both mainstream healthcare and other addiction interventions. "One of my patients who has been on buprenorphine for six months just did his AA Fifth Step with me," said Doot. "You can integrate buprenorphine into psychosocial treatment ... These people are leading meetings."

Acceptance Grows, Along with Need

Since being approved by the Food and Drug Administration (FDA) in 2002 for the management of opioid dependence, buprenorphine has been slowly gaining acceptance among patients and providers as an alternative to methadone maintenance. NIDA's top treatment researcher, Frank Vocci, Ph.D., said that clinical trials of the drug found that the buprenorphine reduces craving with only mild withdrawal symptoms, and as word of the studies has gotten out on the street, other opiate addicts have started asking about the drug.

The formulary of naloxone mixed with buprenorphine has little potential for abuse or diversion, said Vocci, and a study of pharmacies dispensing the drug found that buprenorphine patients were well-received by staff used to dealing with the general public, not addicts.

"It changed their view of people with opiate addiction, not only because they didn't have any trouble with them, but because they became regular customers in the store," noted Vocci.

FDA approval of buprenorphine was well-timed, said Rawson: there are currently 4 million heroin addicts in the U.S., with an increasing supply of the drug coming in from Afghanistan. Moreover, addiction to prescription opiate-based drugs such as Oxycontin has grown to become one of the nation's biggest drug problems.

"We've now identified a whole new cohort of young heroin addicts that will probably expand as more heroin comes from the Middle East," said Rawson. "Many just won't or can't go into methadone treatment. So buprenorphine will play a big role."

"I don't think we yet know what the necessary dose is in supplementing buprenorphine with psychosocial treatment, or the best way to integrate psychosocial treatment with buprenorphine," added Rawson. "The best results so far in small trials have been with intensive partnering and linkage between the medication and the psychosocial treatment. We do know that it's important to provide meaningful psychosocial treatment with buprenorphine therapy."

Used as an adjunct -- not replacement or competition for -- methadone maintenance, buprenorphine has the potential to fundamentally alter the current treatment system. "I don't put heroin addicts in the hospital anymore for detox," Doot said. "This is going to change a lot in the traditional treatment system for opiate addiction ... and we have to be ready for that."

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