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In opioid epidemic, treatment isn't the problem; finding doctors who offer it is

Health officials say they know a treatment that works to address the opioid epidemic: prescription medication that reduces cravings and withdrawal symptoms.

But finding a doctor who offers it can be difficult.

"We know that abstinence-only treatment fails. People relapse," said Dr. Gale Burstein, Erie County health commissioner. "We need more people trained to prescribe drugs like buprenorphine. We're making headway, but the need is very great."

Promising efforts are happening locally to expand the number of doctors, nurse practitioners and physician assistants who can prescribe such medications.

The University at Buffalo's Research Institute on Addictions is leading a statewide program to train medical professionals in high-need regions, including Erie and Niagara counties, in medication-assisted treatment.

Erie County is continuing to head in a similar direction to address the problem. It has trained more than 150 community doctors and other health professionals since September 2016  to use buprenorphine, and it is working with emergency medicine specialists affiliated with UB's Jacobs School of Medicine and Biomedical Sciences to train physicians to start opioid treatment in hospital emergency rooms.

Medication-assisted treatment in combination with counseling is considered the gold standard for controlling opioid addiction. But there are limits on prescribing buprenorphine, a semi-synthetic opioid with a low risk of overdose, and complications in incorporating it into medical practice.

"Once you get trained, it's not an easy transition to getting your first patient. And, once you are treating patients, you have to make sure they are monitored. That can be difficult, especially if you are a single provider," said Kenneth Leonard, director of the Research Institute on Addictions.

The Research Institute is coordinating a statewide program to identify and train doctors and other health professionals in 16 counties and tribal areas in the state where high death and hospitalization rates from opioid abuse have occurred. The effort expands UB’s involvement in the Erie County Opioid Epidemic Task Force, which is coordinating key initiatives in the Buffalo area.

Opioids include the illegal drug heroin, as well as powerful pain relievers available by prescription, such as oxycodone, hydrocodone and fentanyl. Their abuse has led to alarming increases in overdoses and deaths. Erie County recorded 103 opioid-related deaths in 2012 but 301 in 2016. This year, as of Nov. 5, there have been 170 confirmed and 120 suspected deaths.

The Food and Drug Administration approved three medications to help treat opioid addiction: buprenorphine, naltrexone and methadone. They also are known by their brand names, such as Suboxone, which combines buprenorphine and naloxone to prevent tampering and abuse.

One of the advantages of buprenorphine is that, unlike methadone, patients can take it at home instead of making daily visits to a clinic. However, to prescribe buprenorphine, doctors must take a certification course and apply for a waiver from the federal government. This allows them to treat up to 30 patients at one time and, after one year, request to treat up to 100 patients. Physicians who have prescribed buprenorphine to 100 patients for at least one year can then apply to increase their patient limit to 275.

Among the challenges: Some health professionals remain reluctant to get involved with opioids, considering the increased law enforcement scrutiny of opioid prescribing patterns and the extra work to monitor patients long-term. Others interested in prescribing buprenorphine take the training, yet never seek certification. Still, others obtain certification, yet never prescribe.

More than 900,000 doctors in the United States are licensed to prescribe addictive painkillers, but only 43,500 are trained to prescribe buprenorphine. Moreover, only about 1 in 10 of the 21 million Americans with a substance use disorder receive any type of specialty treatment, according to federal reports.

Leonard said the Research Institute's initiative, which is funded by a state grant, intends to find experts in their communities who can serve as local champions to mentor others, as well as to recommend the best way to find candidates for training. It will also offer consultations after the training through telemedicine to help with practical office issues that arise. The idea is similar to Vermont's hub-and-spoke system for administering medication-assisted treatment that attempts to support primary care physicians with the additional work involved with addiction care, such as more frequent check-ins with patients, especially at the start, as well as pill counts and urine tests.

The idea of starting treatment in the emergency room got a big boost from a 2015 Yale University study that found people with opioid-use problems who were treated with the medication buprenorphine in the ER were more likely to stick with treatment after they left compared with patients simply given a referral to treatment. The initiative here is taking the idea a step further with formal links between emergency departments and addiction treatment services, such as Evergreen Health, so that doctors know the high-risk patients they counsel or treat with buprenorphine have a link to further treatment and counseling once they leave the hospital.

"It's frustrating because we know Suboxone works," said Dr. Joshua Lynch, an emergency room doctor at ECMC and Kaleida Health spearheading the initiative to establish medication-assisted addiction treatment in emergency rooms.

In September, Lynch and Dr. Paul Updike, an addiction specialist and director of chemical dependency at Catholic Health, conducted the first training session for emergency department personnel, attracting about 20 people. Updike co-chairs the county's provider education opioid task force committee. Lynch estimated that only three emergency room doctors in Western New York were certified to prescribe buprenorphine before the project started.

Hospitals covered by UBMD emergency room physicians include Kaleida Health facilities, the Veterans Affairs Medical Center, and ECMC. Lynch said the plan is to also include the Catholic Health hospitals as the effort gains a foothold.

A recent study of two of the main drugs for treating opioid addiction – buprenorphine and naltrexone – found them roughly equivalent in effectiveness, but experts say it's uncertain if the head-to-head trial  sponsored by the National Institute on Drug Abuse will increase the use of naltrexone, also sold by the brandname Vivitrol.

Vivitrol, which blocks receptors in the brain to prevent opioids from having an effect, is favored by many in the criminal justice system because patients take it by injection only once a month, and it is not viewed as replacing one opioid drug with another. However, patients must first wean themelves off opioids to avoid withdrawal symptoms, a hurdle for many. About a quarter of the patients in the study who received naltrexone didn't complete detox.

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