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The least you need to know about buprenorphine and PDMPs

March 03, 2017

My colleagues and I saw the new research report from Addiction and were marveling at the findings. A high number of patients receiving buprenorphine for addiction treatment are concurrently, or soon after treatment, also filling separate opioid prescriptions. About 43% filled an opioid prescription during treatment, and 67% filled one after. In all, the percentage of those filling an opioid prescription either during or after treatment was about 73%.

I think I’m correct in saying that this should not be happening. Treatment efficacy aside, opioid prescriptions shouldn’t be dispensed to patients who need and want opioid addiction treatment.

In the journal article, the authors generally aim to crunch the numbers rather than devise solutions, but they do briefly mention the fragmentation of the healthcare system and suggest that prescription drug monitoring programs (PDMPs) might be valuable in avoiding such opioid use. That was certainly my first thought.

Why aren’t PDMPs catching opioid fills for buprenorphine patients?

I talked to a few experts, and here’s the least you need to know.

First, let’s look at the buprenorphine prescriber. Opioid treatment programs (OTPs) and office-based buprenorphine prescribers—the methadone clinics and waivered physicians, respectively—are not currently required to check PDMPs in most states. However, the American Association for the Treatment of Opioid Dependence recommends that buprenorphine prescribers opt to check the PDMPs regardless, according to Mark Parrino, the association’s president.

So, there’s one weak link that might be strengthened at some point.

More complicated is the alternate scenario in which an opioid prescriber, like a primary care physician, for example, would ideally be checking the PDMP for buprenorphine, which itself is an opioid and can be prescribed for pain as well as addiction. Because of 42 CFR Part 2 privacy rules, buprenorphine prescriptions for addiction more often than not are not recorded in the PDMP, according to Sherry Green, president of the National Alliance for Model State Drug Laws. The only way they would be recorded would be if the patient takes a paper prescription order to a pharmacy counter and fills it there. In that case, the pharmacy would record the fill in the database because the law surmises that the patient has chosen to forgo the privacy protection at that point.

Otherwise, buprenorphine dispensed for addiction treatment at the prescriber’s site or with an electronic prescription remains privacy-protected and thus not entered into the PDMP. A primary care physician would remain in the dark about the patient’s buprenorphine treatment.

Let’s not forget that to date, just 13 states require opioid prescribers to check PDMPs, and Missouri still remains the lone state that doesn’t even have a PDMP. So, here’s another, more fundamental, weak link to consider.

What else does the data indicate?

It’s important to note that the study authors used data from January 2010 to July 2012. Although it was an all-payer data set—meaning Medicare, Medicaid, private insurance and cash payment—it was also a relatively old data set. I’d like to think federal and state programs would have sharpened opioid prescribing practices in the past five years and that more current data, if it were available, might show improvement.

There are great talking points to be had here. What solutions do you propose?

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