STRATEGIES TO CONTROL BUPRENORPHINE ABUSE:

On Feb 23rd the Baltimore Sun published the following article.

I wrote to seek clarification from Dr. Fiellin's reference to Physician Clinical Support System's (PCSS) role in physician compliance with buprenorphine prescribing guidelines

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LETTER TO DR. DAVID FIELLIN
RE BALTIMORE SUN FEB 23 ARTICLE
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March 7, 2008

Dear David:

The comments attributed to you by the Baltimore Sun in its Feb. 23 article on “strategies to control bupe abuse” are of concern. Specifically: “’There is not an active surveillance system in place to identify physicians who are practicing outside the guidelines,’ Fiellin said. When they are found, he said, his group will work to report them.”

Which guidelines? All those contained in the 198-page publication, “Clinical guidelines for the use of buprenorphine” – to which you contributed as member of the “buprenorphine expert panel”? Or are there guidelines of particular concern based on evidence that they are causing misuse/abuse/diversion?

What is the plan for “finding” doctors who deviate from the guidelines?

To whom is the ASAM “group” planning to report the doctors it identifies?

It may well be that you were misquoted and/or that your remarks were distorted by being taken out of context. As they stand, however, they surely will dampen the already quite limited enthusiasm of physicians to obtain and utilize the authority to prescribe. I also worry that your sentiments will give impetus to pressure to impose on buprenorphine many of the same demands and restrictions that for decades have served to exclude office-based physicians from caring for opiate-dependent patients with methadone. In any event, physicians prescribing or thinking of prescribing buprenorphine have a right to know what to expect: the practices ASAM plans to monitor and how, and to whom non-compliance will be reported. Notification to all waivered physicians of ASAM’s intentions should be easy to arrange. I urge you and ASAM to do so.

Sincerely
Bob Newman, MD

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RESPONSE BY DR. DAVID FIELLIN:
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Bob,

Thank you for your letter.

I spoke at this press conference as Medical Director of the PCSS, not as an employee or member of ASAM.

As you have suggested, I was indeed misquoted. I am also disappointed that the Baltimore Sun choose not to print my letter to the editor regarding their series on buprenorphine.

The guidelines that I referred to include the CSAT TIP #40 and the Guidance produced by the Federation of State Medical Boards.

Both of these documents recommend that stabilized patients be seen on a regular basis (e.g. monthly) and that patients who are early on in the recovery process be seen more frequently and have access to physician and counseling services.

The PCSS has no role in active surveillance of physicians but exists primarily as an educational resource to assist clinicians in providing quality care to opioid dependent patients. To help them get over the reticence that you discuss.

My statement was that the PCSS mentors are encouraged to work with state medical societies if there are concerns about inappropriate prescribing behaviors. We have occasionally received reports about physicians who do not have a modified DEA registration who are prescribing large quantities of buprenorphine, offering no office or counseling services and the like. My hope is that the medical societies and the medical profession can work to limit these events and respond within our profession so that we do not end up with significant restrictions, from federal agencies, that limit the availability of office-based treatment of opioid dependence.

I hope you agree. Thanks,

David

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COMMENT BY DR. MIKE MILLER,
PRESIDENT AND BOARD CHAIR, ASAM
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David:

1. Thanks for your leadership of PCSS.
2. Thanks for your excellent letter to the Baltimore Sun. I agree, it's a shame they didn't publish it.
3. Thanks for your reply to Bob.

Bob: Thanks for bringing this to our attention. You are surely not the only ASAM member, or patient of an ASAM member, who has seen the article, on the web or even on their news stand in Baltimore, and wondered, 'Huh??'

This is such a delicate topic: it occurs to me, David, that your response to Bob, or something like it, could be posted on the ASAM website, and published in ASAM News. ASAM has no role, and CSAT's PCSS, administered by ASAM, has no role, in monitoring physician practice, cataloging deviatiations from standards of care, or reporting physicians to regulatory or licensing agencies. Individual physicans are bound by our code of ethics, however, to report egregious physician behavior when we are aware of it.

This really is a delicate topic, and shining light on it is warranted especially in the current environment, stirred up by the editorial board of the Baltimore Sun, in which partial truths, misquotes, and other misinformation is harming the ability to expand an incredibly successful public health intervention to more patients in need. Plants need light and mud to grow; in this case, more light and less mud would be a good thing.

Mike

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Michael M. Miller, MD, FASAM, FAPA
President and Board Chair, ASAM