Addiction Medicine: Closing the Gap between Science and Practice

generalizability of research-based efficacy
findings to different patient populations.^86

Although one study found that each additional
physician on staff in a treatment program was
associated with a doubling of the odds that the
program would adopt the use of pharmaceutical
treatments for addiction,^87 having access to a
staff physician does not guarantee access to or
use of pharmaceutical treatments.^88 One study
found that 82 percent of publicly-funded
addiction treatment programs with access to a
physician did not prescribe any treatment
medications for addiction involving alcohol; the
same is true of 41 percent of privately-funded
treatment programs with access to a prescribing
physician.^89

The treatment of addiction involving opioids
presents one of the most glaring examples of the
underutilization of clinically-effective and cost-
effective pharmaceutical treatments for
addiction.^91 Buprenorphine is a pharmaceutical
treatment for addiction involving opioids that,
despite a rich body of evidence demonstrating its
efficacy, safety^92 and cost effectiveness,^93 is
significantly underutilized in practice.^94 The
majority (86 percent) of addiction counselors
report not being aware of the effectiveness of
buprenorphine.^95

Specific additional obstacles to the widespread
use of buprenorphine by physicians include cost,
lack of insurance coverage and availability
problems due to pharmacies not stocking the
medication.^97

Physicians’ biases against patients with
addiction may contribute to the limited adoption
of pharmaceutical treatments as well.^98 Survey
results from a random sample of internal

medicine, family medicine, psychiatry and pain

management physicians in Maryland found that

only 36 percent of respondents were willing to

prescribe buprenorphine to an established patient

and only 28 percent were willing to prescribe the

medication to a new patient. Seventeen percent

of physicians unwilling to prescribe the

medication said that addiction involving opioids

is best described as a habit rather than an illness;

none of the physicians willing to prescribe the

medication agreed with this statement. Half of

the Maryland doctors who were not willing to

prescribe buprenorphine reported that they

believe that treatment for addiction involving

opioids is beyond the scope of practice of office-

based physicians and 46 percent reported not

wanting patients with addiction involving

opioids in their clinics.^99

The fact that buprenorphine can be prescribed in

physicians’ offices for at-home use was heralded

as a step forward in the treatment of addiction

involving opioids. Addiction professionals

anticipated the medication’s potential to help

addiction treatment become a more central

component of medical practice.^101 However,

these hopes have not come to fruition.^102

The reason I am not interested [in prescribing

buprenorphine] is I see this as an opportunity for

drug users who are by class the most lying,

scheming, dishonest group of patients. They need

hard-based, no-nonsense treatment programs. I

can’t stand their manipulative behavior.^90

Anonymous Physician

We’re seeing less interest [in prescribing

buprenorphine] than we expected, especially

among primary care physicians.^96

--Robert Lubran, MPA

Director

Division of Pharmacological Therapies

Center for Substance Abuse Treatment (CSAT)

SAMHSA

There is no other comparable example in

medicine where you have evidence-based

treatments that are not available.^100

--Shelly Greenfield, MD, MPH

Chief Academic Officer, McLean Hospital

Professor of Psychiatry,

Harvard Medical School

Director, Clinical and Health Services Research

and Education Division of Alcohol

and Drug Abuse, McLean Hospital