For more information, call the Center for Substance Abuse Treatment (CSAT) Buprenorphine Information Center toll-free at 1 (866) BUP-CSAT or 1 (866) 287-2728 on weekdays between 8:30 a.m. and 5 p.m., eastern time, or e-mail info@buprenorphine.samhsa.gov. For Physicians and Health Care Providers

On SAMHSA's Web site, visit www.buprenorphine.samhsa.gov. Click on "Buprenorphine Publications" to download a copy of the Buprenorphine Curriculum for Physicians. The online course for counselors is available free of charge at www.ceattc.org.

CSAT will release in the near future a Treatment Improvement Protocol (TIP), Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. To check on the TIP's availability, contact the National Clearinghouse for Alcohol and Drug Information (see next bullet).

For Patients and Their Families

An informational brochure is available from CSAT-Introducing Office-Based Treatment for Opioid

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overcome some of the potential barriers to prescribing the medication.

"Qualified physicians are now able to prescribe a therapeutic controlled medication in an office setting," said SAMHSA Administrator Charles G. Curie, M.A., A.C.S.W. "Now, buprenorphine allows physicians to treat opioid addiction just like they treat diabetes, hypertension, or any other chronic disease."

Addiction. To order this free brochure (in English or Spanish), contact the National Clearinghouse for Alcohol and Drug Information (NCADI) at P.O. Box 2345, Rockville, MD 20847-2345. Telephone: 1 (800) 729-6686 (English and Spanish) or 1 (800) 487-4889 (TDD). ⚫ To find a doctor authorized to prescribe buprenorphine, check CSAT's Buprenorphine Physician Locator at http://buprenorphine.samhsa.gov.▸

Training Physicians

Treating patients with buprenorphine involves more than just writing a prescription. To comply with the Drug Addiction Treatment Act of 2000, physicians who want to prescribe the medication for use in detoxification or maintenance treatment must first obtain a waiver from SAMHSA that exempts them from certain Federal requirements related to the prescribing of controlled substances. To qualify for the

waiver, licensed physicians must have subspecialty board certification in addiction medicine or undergo at least 8 hours of approved training in buprenorphine use. To help physicians meet these requirements, CSAT funded the development of a curriculum to be used in these 8-hour training sessions. A consensus panel of addiction medicine experts representing three medical societies-the American Academy of Addiction Psychiatry (AAAP), the American Osteopathic Academy of Addiction Medicine (AOAAM), and the American Society of Addiction Medicine (ASAM)— developed the curriculum.

Use of Buprenorphine in the Pharmacologic Management of Opioid Dependence: A Curriculum for Physicians gives trainers an easy way to prepare lectures and other educational activities related to buprenorphine treatment. The curriculum includes sample slides and sample questions trainers can use to develop pre- and posttraining tests, for instance.

"The goal of the curriculum is to provide a structured, uniform set of materials that address a variety of important issues in the treatment of opioid-dependent patients," said David A. Fiellin, M.D., an associate professor of medicine at Yale University Medical School, who helped write the curriculum in his role as chair of

ASAM's Buprenorphine Training Subcommittee. "We wanted to develop the curriculum in such a way that it would be appropriate for both specialists in addiction medicine and generalists."

To meet those goals, the curriculum begins with an overview of the legislation and pharmacology behind buprenorphine as well as a discussion of nonpharmacological treatment of opioid-dependent patients. Another section explains how to assess and select patients for treatment, including discussions of what to do when a patient has other psychiatric or medical problems beyond opioid addiction. A large part of the

curriculum focuses on the logistical aspects of buprenorphine treatment, including sections on protecting a patient's privacy, establishing appropriate office policies and procedures, and keeping good medical records. The curriculum concludes with several case studies.

Estimating that trainers use about 80 percent of the curriculum's slides in their current form, Dr. Fiellin noted that he and other trainers are already modifying the slides or adding slides of their own. When Dr. Fiellin gives trainings, for example, he adds information about incorporating psychosocial treatment into an office-based setting. Dr. Dekker's trainings feature more detailed information about prescription drug abuse than the basic curriculum offers. Using the Curriculum

In addition to funding the curriculum's development, CSAT is providing support for the trainings where Dr. Fiellin, Dr. Dekker, and other experts use the curriculum. Buprenorphine's manufacturer recently decided to provide additional funding for training. Sponsored by the three medical societies involved in the curriculum's development as well as the American Psychiatric Association (APA), these ongoing training events are taking place nationwide. AAAP and APA also offer Web-based instruction that allows physicians to get their training online.

As of February, 3,722 physicians had been trained in the use of buprenorphine. So far, the trainings have attracted addiction specialists who technically don't need the training but who want to learn more about buprenorphine. Trainings also attract primary care physicians. "Most physicians are not addiction specialists. The more we can get primary care physicians interested in taking a course, the greater the likelihood they will become interested in treating this population," stated H. Westley Clark, M.D., J.D., M.P.H., CSAT Director.

continued on page 4

From the Administrator

Buprenorphine Treatment: How Is It Working?

When the medication buprenorphine was approved by the Food and Drug Administration for clinical use in 2002, it was hailed as a milestone in the treatment of addiction to illicit opiates such as heroin and certain prescription painkillers such as codeine and oxycodone.

Buprenorphine is said to be longlasting, with minimal side effects and a low potential for abuse. It is also the only controlled substance approved for the treatment of opioid addiction that may be prescribed by physicians in an office-based setting as opposed to a specialty clinic.

With these advantages, buprenorphine increases the number of tools service providers can use to treat addiction. This medication also expands the availability and accessibility of substance abuse treatmenta priority for the Bush Administration, the U.S. Department of Health and Human Services, and SAMHSA.

But the availability of a new medication is only one part of the story; its adoption into clinical practice is another. Incorporating buprenorphine into treatment raises many questions. For example:

• What special training do physicians need to prescribe or dispense buprenorphine and how do they obtain this training? How do physicians coordinate buprenorphine treatment with addiction treatment counselors and what kind of training do these counselors need?

What are some of the challenges and barriers to the use of buprenorphine in clinical practice, and how can SAMHSA help

surmount these?

How do addiction treatment providers see buprenorphine affecting their clinical practices? How can lessons learned from using buprenorphine in clinical practice increase acceptance and enhance the

overall use of medical approaches in the treatment of addiction?

These kinds of questions are of particular concern to us at SAMHSA. Our Agency seeks to serve as the conduit between the information gained from research and the knowledge gleaned from clinical practice; the synapse between science and service. We view the constant interchange between the two as a catalyst that fuels the advancement and enhancement of recovery.

This issue of SAMHSA News explores some of the emerging developments as buprenorphine is integrated into treatment. Articles also describe SAMHSA-funded efforts to train service providers to administer the medication and grassroots efforts that include buprenorphine to combat opioid use and addiction in the community.

Medications such as buprenorphine, along with psychosocial supports, can help people addicted to opiates stop craving their drugs and re-establish productive and fulfilling lives in the community. Buprenorphine alone is not a silver bullet for opioid addiction, but it can open the door to recovery and provide the opportunity to regain lost lives. ▸

Farles Gren
Кат

Charles G. Curie, M.A., A.C.S.W.
Administrator, SAMHSA

continued from page 3

Now CSAT is reaching out to other organizations that can help bring in more physicians. The Health Resources and Services Administration's HIV/AIDS Bureau, for instance, is working to convince physicians that treating opioid addiction can enhance prevention as well as adherence to HIV treatment regimens. CSAT is also working with ASAM and other organizations to educate physicians involved in pain management about buprenorphine's role in treating patients addicted to prescription narcotics.

Overcoming Barriers

More than 2,500 physicians have

received their waivers so far. And,
approximately 1,700 are listed on CSAT's
Buprenorphine Physician Locator
(see "Resources" on page 2).

Buprenorphine is proving to be beneficial in rural areas, which often lack alternative treatment options. "Mostly jail" is how Art Van Zee, M.D., a general internist at the St. Charles Clinic described the prebuprenorphine treatment options when prescription drug abuse first hit his tiny coal-mining town in southwestern Virginia. The nearest methadone clinic is more than an hour away. As far as Dr. Van Zee knows, he is the only physician within 60 miles qualified to prescribe buprenorphine.

However, buprenorphine is no magic bullet. For one thing, some physicians just aren't interested in treating patients with

opioid dependence. "This is not a group of patients who are appealing to some physicians," said George Kolodner, M.D., Director of Chemical Dependence at Georgetown University Hospital and Medical School. "They have a history of antisocial behavior and a reputation of being difficult to manage."

"Buprenorphine allows physicians to treat opioid addiction just like they treat diabetes, hypertension, or any other chronic disease."

-Charles G. Curie, M.A., A.C.S.W.
SAMHSA Administrator

The intensive patient management that buprenorphine requires at the beginning of the treatment process seems to be an additional deterrent, especially for physicians in solo private practices. The Drug Addiction Treatment Act limits individual and group physicians from having more than 30 patients on buprenorphine at one time. Because many patients may remain on buprenorphine long term, this patient limit means that some practices are already at capacity. It also means that some physicians especially those in primary care practice-are deciding that buprenorphine treatment is not for them.

"Primary care doctors are swamped as it is," said Dr. Dekker. "Why would they want to jump through these hoops to take care of such a small number of drug-addicted patients rather than just refer them to someone else?"