APA Comments on Buprenorphine Guidelines

February 14, 2000

The Honorable Thomas J. Bliley, Jr.
Chair, House Commerce Committee
2125 Rayburn House Office Building
Washington, DC 20515

Dear Mr. Chairman:

In the coming weeks, the House Commerce Committee is expected to consider legislation to control methamphetamine abuse. As you know, the “Methamphetamine Anti-Proliferation Act of 1999” (S. 486) passed the Senate by unanimous consent on November 19. I am writing on behalf of the 159,000 members and affiliates of the American Psychological Association (APA) to request that the registration waiver provision included in the Senate-passed bill (with two proposed changes described below) be incorporated into any House-passed legislation

The specific provision of S. 486 that APA would like to see added is designated as Section 211 under Subtitle B (Other Matters) of Title II (Controlled Substances Generally). This section waives registration requirements for physicians who dispense Schedule IV and/or V narcotic drugs for maintenance or detoxification treatment. It should be noted that this favorable provision diverges significantly from prevailing practice by permitting primary care physicians to prescribe certain narcotics, specifically buprenorphine, for the treatment of addiction. While methadone, in combination with psychosocial services, has proven to be an effective and essential treatment for individuals addicted to narcotics, the methadone clinic model has not reached a notable segment of this population. Some of these individuals, who tend to be gainfully employed with family and community ties and no evidence of anti-social behavior, have shied away from methadone clinics out of concern for stigmatization and could be medically managed by primary care physicians. As demonstrated by research studies, the administration of buprenorphine by primary care physicians offers a safe, effective, and more widely accessible treatment alternative for these and other individuals addicted to opiates.

However, to help ensure the successful utilization of buprenorphine, it is essential to promote the need for a thorough assessment of the patient within an integrated treatment model, which includes behavioral and psychosocial services. To accomplish this goal, two specific provisions in S.486 that pertain to referral for counseling and to training requirements for primary care physicians need to be strengthened.

With respect to the counseling referral provision, the language in S.486 that “the physician has the capacity to refer the patients for appropriate counseling and other appropriate ancillary services” does not effectively encourage such referrals. A physician in any context has “the capacity to refer.” Accordingly, we propose the following substitute language for this provision (with the bracketed section to be replaced with the bolded language):

SEC. 211 (B) (II) With respect to patients to whom the physician will provide such drugs or combinations of drugs, the physician [has the capacity to refer the patients for appropriate counseling] will strongly encourage the patients to seek appropriate counseling and behavioral therapy, and other appropriate ancillary services.

This recommendation is in keeping with 4 of the 13 principles of effective treatment espoused by the National Institute on Drug Abuse in its Principles of Drug Addiction Treatment: A Research-Based Guide. The sixth stated principle is most directly on point – “Counseling (individual and/or group) and other behavioral therapies are critical components of effective treatment for addiction.”

Our second recommendation concerns the training of physicians. Since the treatment of patients would shift to physicians in office-based practices, it is critical to ensure the adequate training of such physicians. In this regard, S.486 stipulates that physicians must meet one or more of six stated qualifications. While five of these are beyond dispute (e.g., board certification in addiction treatment), the one outlining training programs is too broad as written. Ostensibly, a physician could attend a one-hour seminar, which does not cover critical related treatment issues, and be deemed eligible to prescribe buprenorphine. To address this deficiency in S.486, we propose adding the following bolded words and deleting the bracketed word:

SEC. 211 (B) (IV) (cc) The physician has completed training of no less than a total of 24 hours (through classroom situations, seminars, professional society meetings, electronic communications, or otherwise)…The curricula [may] must include training in patient need for psychosocial intervention, counseling regarding HIV, Hepatitis C, and other infectious diseases, substance abuse counseling…

In closing, I would like to commend you for your leadership as Chair of the House Commerce Committee in attempting to reach consensus on such a complex issue as drug addiction. In this regard, it is our understanding that the recommendations we have proposed would be well received by the National Institute on Drug Abuse (NIDA) and by the Center for Substance Abuse Treatment (CSAT). I should add that two of our APA member divisions, the Division on Addictions and the Division of Psychopharmacology and Substance, are expressly interested in and informed about our nation’s public policy toward substance abuse treatment.

We hope these comments prove helpful to you in your committee deliberations. If APA can be of any further assistance, please contact Ellen Garrison, Ph.D., or Denis Nissim-Sabat, Ph.D., of our Public Policy Office at (202) 336-6062.

Sincerely,

L. Michael Honaker, Ph.D.

Deputy Chief Executive Officer

Cc: The Honorable John D. Dingell, Ranking Member

Dr. Westley Clark, CSAT Director
Dr. Alan Leshner, NIDA Director

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