From the Journals

Most U.S. buprenorphine prescribers assess patients for diversion



Most prescribers of buprenorphine view diversion or misappropriation of the drug as a concern, and most assess their patients for diversion, according to Lewei (Allison) Lin, MD, and her associates.

In a survey of 1,174 buprenorphine prescribers conducted from July 2014 to January 2017, 79% of the prescribers reported assessing all their patients for diversion of the drug, and 79.1% reported conducting urine tests for the presence of buprenorphine. In addition, 85% of prescribers viewed diversion as a problem in their community, and 80.3% of prescribers were willing to terminate treatment because of diversion, reported Dr. Lin of the department of psychiatry at the University of Michigan, Ann Arbor, and her associates in Drug and Alcohol Dependence.

Diversion was defined as “unauthorized rerouting or misappropriation of prescribed buprenorphine to someone other than the person for whom it was intended.”

Dr. Lin and her associates found that prescribers were more likely to assess all of their patients for diversion if they viewed diversion as a problem in their community, had fewer years of experience, or were white. Urine testing was more likely if prescribers viewed diversion as a problem in their community, had more patients, had less experience, had a 100-patient waiver, or were nonpsychiatrists. Treatment termination was more likely for prescribers who had a greater percentages of patients with medication counts, viewed diversion as a problem in their community, or practiced in nonaddiction/nonpsychiatric specialties.

“Although we did not include detailed questions about termination, the high proportion of prescribers who would terminate patients for diversion is important to note,” wrote Dr. Lin, also a research investigator at the VA Center for Clinical Management Research, Ann Arbor, and her associates. Addiction medicine specialists and psychiatrists were less likely to terminate patients because of concerns about diversion – which suggests that additional training in addiction might make clinicians more comfortable managing patients with high-risk behaviors, the investigators said.

They cited several limitations. For example, the survey’s cross-sectional design makes causal inferences difficult. In addition, when the survey was conducted, physicians were the only buprenorphine prescribers. It is therefore unclear whether the study results are generalizable to physician assistants or nurse practitioners, who now are able to prescribe buprenorphine after meeting certain requirements.

Still, the study uncovered new information about the steps that prescribers take to mitigate diversion. “Addressing diversion is a complex clinical dilemma and contextual factors, including availability of services, may need to be explored in the future alongside provider practices addressing diversion,” the investigators wrote.

SOURCE: LA Lin et al. Drug Alcohol Depend. 2018 May 1. doi: 10.1016/j.drugalcdep.2018.01.015.

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