Why Are There Waiting Lists for Buprenorphine?

By Dr. Richard Juman 07/02/15

What can be done to get medications like Suboxone to more people?


Dependence on opioids, both prescribed medications and heroin, is one of the most serious public health problems in the United States, with approximately three million people involved. The number of opioid-related overdoses is a national tragedy, with overdose now causing more deaths than automobile accidents. Looking at heroin, the number of deaths associated with heroin rose for the third consecutive year in 2014, with a stunning 39% rise from the previous year. 

One of the most effective pharmacologic treatments for opioid use disorders, buprenorphine (brand names: Suboxone, Zubsolv, Subutex), can be prescribed in outpatient settings such as physicians’ offices, which makes it a great option as compared with methadone, which generally requires daily visits to outpatient clinics. Unfortunately for patient access, only physicians are permitted to prescribe buprenorphine, and each MD can prescribe to only 100 patients at a time. Nurse practitioners and physician assistants are not allowed to prescribe buprenorphine for opioid dependence—the only scenario in which the use of a Schedule III medication is confined to physicians. 

Christene Amabile, FNP-BC is a nurse practitioner working in the field of addiction medicine at Horizon Health Services, the largest behavioral health organization in Western New York. Paige Prentice is Vice President of Operations for Horizon Health Services and serves on the board of NYASAP (New York Alcoholism and Substances Abuse Providers). Christene and Paige have argued (see page 6 here) that these restrictions do not serve the public but rather create shortages of providers and long wait times for access to buprenorphine, during which times opioid users are vulnerable to overdose and death. They advocate for improving access to treatment by permitting nurse practitioners and physician assistants to prescribe buprenorphine….Richard Juman

Richard Juman: I know that there are regional differences with respect to access to Medication-Assisted Treatment (MAT), especially buprenorphine. It sounds like it can be difficult for people in your region to find the help that they need?

Christene and Paige: There are similar needs across the states, because of the federal limitations imposed on the prescription limitation of buprenorphine. It is very difficult to meet the buprenorphine needs here in Western New York. Issues include restricted access (because federal limitations dictate that only qualifying doctors with specialized eight-hour training can prescribe buprenorphine, and there is a 100 patient limit). As a result, there is a shortage of doctors that do prescribe buprenorphine, and although nurse practitioners and physician assistants are able to prescribe all other controlled substances in NYS (including buprenorphine for pain management), they are unable to prescribe it for the treatment of opiate use disorders (OUD). 

There are other issues as well. There can be problems with insurance companies denying coverage. Also, some doctors that do prescribe only accept cash (often as high as $300 for the initial appointment and $175 for each follow-up appointment), which many patients can’t afford. When you have a condition that can benefit from a medication to help control it, and you are ready to do something about it today…you need the medication today. The barriers here can result in this medication not being available for days or weeks—days to get prior authorization by an insurance company for coverage and days, or weeks, to locate a doctor that can see the patient for the medication assessment.

RJ: How do the physicians in your area manage the 100 patient limit? Do they tend to maintain 100 patients on buprenorphine and set up a waiting list, or do they have to aggressively titrate down and then discharge patients in order to make room for new patients who can't find treatment?

CM/PP: We can only speak about the physicians within our agency. We maintain the 100 patients per physician limit. This in turn creates a waiting list for those who are in need of Medication-Assisted Treatment with buprenorphine (Brand names: Suboxone, Zubsolv, Subutex). Currently, within our agency, patients wait four to six weeks to see a physician for their buprenorphine prescription. The wait for this medication is similar at other agencies and in private practice offices. We are unaware of any prescribers who quickly taper medication in an attempt to assist new patients. It is simply unacceptable that people have to wait this long for a potentially lifesaving medication.

Another unfortunate aspect of this scenario is that, in part, this high demand for buprenorphine, and the low supply, give buprenorphine a high “street” value. There is a misconception that patients (or others) want buprenorphine to get high. Buprenorphine, is a partial opiate and when used properly, does not produce a “high.” The value and intended purpose of this medication is to curb withdrawal symptoms and manage the relentless cravings that are often experienced by individuals with an opiate use disorder. It’s a demand versus supply issue. The demand is extremely high and the supply is limited. One of the ways to manage the limited supply is to allow nurse practitioners and physician assistants to prescribe buprenorphine for opioid use disorder. This in turn would reduce the demand, thus decreasing the diversion of buprenorphine, “on the street.”

RJ:  What do you find is the best way to manage patients who are waiting for Medication Assisted Treatment? 

CM/PP: This is perhaps one of the most challenging aspects of working in the field of substance use disorders. We try a combination of strategies to manage patients on a waitlist for MAT. First, intensifying treatment at the outpatient level, hoping the increased support can help them hang on. We also attempt to provide them with comfort meds—something that can help curb the nausea, joint aches and other ailments associated with the withdrawal that happens when patients attempt to control their use. When that fails, we attempt to get them into a more structured setting, which means inpatient or intensive residential. This is obviously a more costly alternative.

Additionally, while someone is awaiting their appointment for MAT with buprenorphine, it is important to discuss safety issues, since clients with an opiate use disorder are often times at high risk for overdose. We teach clients how to avoid the behaviors that put them at risk for illness and overdose. Our agency provides opiate overdose prevention training with Narcan and we provide this training to clients, their families and to any interested community members. Of course, if nurse practitioners and physician assistants could prescribe buprenorphine to treat opiate use disorders there would not be the need to have people on a waitlist, or it would be markedly diminished. We believe that it is imperative that the law is changed to allow this to happen. 

Richard Juman—a licensed clinical psychologist who has worked in the integrated health care arena for over 25 years providing direct clinical care, supervision, program development and administration across multiple settings—is also former President of the New York State Psychological Association. [[email protected]] Find him on twitter—@richardjuman

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Dr. Richard Juman is a licensed clinical psychologist who has worked in the field of addiction for over 25 years. He has treated hundreds of patients as a clinician and also provided supervision, program development and administration in a variety of settings including acute care hospitals, long term care facilities and outpatient chemical dependency centers. Find him on LinkedIn and Twitter.