SAMHSA Bupe Guideline Falls Short

The newly released buprenorphine maintenance “Advisor” overemphasizes control at the expense of harm reduction. According to the guideline “Concurrent behavioral treatment is a critical element of MAT.” and “models of behavioral treatment” including “Cognitive–behavioral therapies... Contingency management... Relapse prevention... Motivational interviewing” “help patients engage in the treatment process, modify their attitudes and behaviors related to drug and alcohol abuse, and increase healthy life skills. These treatments can also enhance the effectiveness of medications and help people stay in treatment longer.”

The guideline fails specify what these treatments treat, how to match the treatment to the patient, and when the treatment has achieved the desired goal. In fact perpetuating the illusion that “behavioral” treatment will ensure abstinence after discontinuation of buprenorphine places patients at risk of relapse and even death. This perfunctory requirement in most cases will provide little more than monitoring and a paid buddy while allowing the clinic to extract even more money from payers and patients.

The guideline continues to promote “pill counts,” as inappropriate activity for clinicians as anything related to prevention of diversion. Physicians’ roles should center on diagnosis and treatment, not law enforcement. Such role distortion interferes with our ability to provide optimal treatment. Let pharmacists count pills. They have the training.

One glaring omission may most clearly reveal the underlying restrictive and pejorative attitude perpetuated by this guideline. The authors fail to address an obvious threat to retention in treatment: If a buprenorphine maintenance patient cannot rely on their physician to assure continued supply of the drug, they will likely relapse with other drugs or obtain the drug from another source. The guideline should emphasize that patients taking buprenorphine or any other critical drug should maintain at least a 3 day emergency supply. Physicians should consistently provide refills at least by the next business day for patients who comply with other requirements of maintenance.

Prohibition does more harm than good. Buprenorphine should be available over-the-counter just like the arguably much more dangerous tobacco and alcohol.

 

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