The most effective treatment for people addicted to opioids - which include illegal drugs such as heroin and prescription medications such as OxyContin and Vicodin - is "substitution therapy" in which patients are given a safer opioid medication that helps prevent withdrawal and relapse to drug abuse. Opioid substitution therapy works best when combined with counseling services and other addiction recovery programs, and has been shown to decrease death rates in opioid addicted patients (National Consensus Development Panel on Effective Treatment of Opiate Addiction, 1998).
Methadone maintenance therapy has long been viewed as the gold standard for substitution therapy. However, due to concerns about abuse and overdose, methadone treatment for opioid addiction is limited to specially licensed programs that usually require daily visits from patients (Kleber 2008). This restrictive environment is a key reason why methadone reaches less than 15% to 20% of patients needing treatment for opioid addiction (Mark, Woody, et al. 2001; Center for Substance Abuse Treatment 2005).
Buprenorphine is a newly approved medication that is an effective alternative to methadone. Because it is safer and less susceptible to abuse, recently enacted federal legislation has permitted buprenorphine treatment to be delivered by qualified physicians in their offices, in addition to specialty treatment programs. This change in the way treatment is provided has allowed substitution therapy to be offered to more patients, in more locations, at earlier stages of disease (Fiellin, Rosenheck, et al., 2001; Sullivan, Chawarski, et al., 2005).
While a growing body of evidence demonstrates the effectiveness of treatment with buprenorphine, there remain numerous barriers that are limiting its impact on both the individual and societal burdens of opioid addiction. Currently, the key impediments to its wider use are related to restrictions imposed by insurers and limits on physician prescribing.
The cost of the drug ($140 to $420 per month) has led some insurers to restrict access to the medication (Schackman, Merrill, et al. 2006). A number of insurers simply refuse to cover the medication at all. In addition, only physicians who complete 8 hours of special training and receive an exemption from the U.S. Drug Enforcement Administration (DEA) may legally prescribe buprenorphine. The fact that physicians must complete this training, that only physicians can prescribe the medication, and that the number of patients that each physician may treat with the medication is restricted by law further limits access to this treatment (Fiellin and O'Connor 2002).
There are also concerns that, in the future, changing perceptions regarding the safety and abuse of buprenorphine could limit its availability for treatment. Although overdoses on methadone and other pharmaceutical opioids are far more common and more dangerous, any increase in diversion of the medication for illegal use or any perception that buprenorphine poses a community risk could prompt policy makers to tighten controls.