These are complicated patients who at times are difficult to manage, and there is still a lot of stigma and unease among doctors about how to care for them, he said.
“It's clearly a positive for the field. It's going to improve things, but is it going to be a panacea? I doubt it,” he said, adding: “I'm cautiously optimistic.”
Dr. Thomas Kosten, former director of the U.S. National Buprenorphine Implementation Program and currently a professor in the psychiatry and neuroscience departments at Baylor College of Medicine, Houston, also expressed cautious optimism about expanded access to care for opioid-dependent patients.
“I can't imagine psychiatrists performing the minor surgical procedure involved with buprenorphine implants, but it is certainly within the purview of many internists and general practitioners,” he said, noting that in many cases in primary care, the machinery is already set up for providing such office procedures, and – in the case of Vivitrol – for providing injections.
“In fact, they would be more comfortable and better equipped to do this,” said Dr. Kosten, who also is research director of the Veterans Health Administration's National Substance Use Disorders Quality Enhancement Research Initiative, based in Houston.
A challenge might be in ensuring that patients receive counseling as needed, but research is increasingly indicating that patients can do well on medications alone if they remain compliant, so concern may be moot, he added.
Another deterrent for many providers has been the requirement of government-sponsored training and oversight of physicians who wish to prescribe buprenorphine.
Dr. H. Berryman Edwards, a psychiatrist in private practice in Bellevue, Wash., and an outspoken critic of the U.S. Drug Enforcement Administration's “disruptive” approach to the oversight of physicians who do prescribe buprenorphine, agreed that psychiatrists aren't likely to use the implantable formulation. But he acknowledged that for primary care doctors and others who embrace this new formulation, it eliminates many of the concerns about diversion and compliance that have deterred physicians from using the treatment in the past.
It will take a certain level of commitment from those who have a desire to use these treatments in the primary care office setting, said Dr. Andrew J. Saxon, a professor of psychiatry and behavioral sciences at the University of Washington, Seattle, and one of the site investigators for the implantable buprenorphine study.
While most primary care doctors probably won't have an interest, those who are willing to learn the implantation procedure – which can be a bit time consuming – and who undergo the required training, will certainly be able to provide this treatment in the office setting. In some cases, it may be that the implants are done elsewhere but patients are followed by their primary care physician, he said.
Vivitrol, on the other hand, could quite easily be provided in the primary care setting. He described Vivitrol as “a pharmacological treatment that is almost perfection,” largely because of the requirement that patients be off opioids before they can receive it.
Vivitrol is safe, he said, with one exception: Patients receiving it will have a decreased tolerance for opioids, and may be at an increased risk of overdose. The overdose risk must be closely monitored, but overall, the treatment has the potential to be a tremendous advantage, Dr. Saxon said.
Dr. Volkow and Dr. Edwards reported having no conflicts of interest. Dr. Friedmann has studied Vivitrol and has received in-kind donations of the medication for his research. He is on the speakers bureau for Reckitt Benckiser Pharmaceuticals, the maker of the sublingual formulation of buprenorphine. Dr. Kosten has served as a consultant to Reckitt Benckiser and to Alkermes. He has served on the data safety monitoring board for Titan Pharmaceuticals, which makes the implantable buprenorphine. Dr. Saxon has served as a consultant to Reckitt Benckiser, and was a site investigator for the Titan-sponsored buprenorphine implant study.
Vivitrol and the implantable form of buprenorphine could improve outcomes for patients who abuse opioids and those addicted to heroin, Dr. Nora D. Volkow says.
Source Courtesy National Institute on Drug Abuse (NIDA)