Should GPs be able to prescribe buprenorphine without restriction?

Since 1995, France has played host to a natural experiment.
 
That was the year that all registered doctors were allowed to prescribe buprenorphine without the need for additional training or licensing.
 
The move was in response to a spike in heroin-related fatalities, with deaths climbing 10% a year.
 
Almost overnight, French GPs overtook addiction specialists to become the main prescribers of the drug, which is an effective treatment for opioid addiction that acts to reduce cravings without becoming addictive.
 
Deaths fell rapidly, dropping by 79% within four years. Research by French addiction medicine specialist Professor Marc Auriacombe and colleagues found the drug had a ‘strong protective factor’ against mortality.
 
Professor Auriacombe, of the University of Bordeaux, presented his latest research at this month’s International Medicine in Addiction Conference in Melbourne, outlining his finding that the greatest impact on opioid-related mortality had been in nations that had made buprenorphine more readily available in primary care settings.
 
Monash University Associate Professor Suzanne Nielsen, who specialises in addiction medicine research, said the research raises questions about why Australia has been more restrictive around GP prescribing of the Schedule 8 drug – particularly as deaths from opioids have almost doubled in the last decade.
 
‘The French Government took a public-health approach to making treatment available. GPs in France have been able to have a huge impact on mortality and related harms by prescribing buprenorphine,’ Associate Professor Nielsen told newsGP.
 
‘It raises questions over why we have such restrictions on it, given it is a very safe opioid.
 
‘What we need to do is work out ways of increasing the availability of this treatment, which not only reduces mortality but also reduces societal harms such as crime and healthcare costs.’
 
In a recent Drug and Alcohol Review editorial, Associate Professor Nielsen and her co-authors call for urgent investment in opioid treatment to avoid the crisis gripping the US and Canada.
 
‘Opioid treatment paradigms [in both mode of delivery and funding] remain largely unaltered since the 1980s and fail to meet the needs of the changing populations of people who use opioids,’ Associate Professor Nielsen and her co-authors write.
 
‘The nature of opioid use and treatment options has changed dramatically in these past decades. The treatment system needs to change with it.
 
‘Despite changes in recent years that allow greater prescribing of opioid agonists in primary care, primary care providers are reluctant to take on this role, meaning that other models of care are needed.
 
‘Much evidence clearly demonstrates that opioid agonist treatment is an effective strategy to reduce opioid-related mortality, and this supports evidence that expanding treatment availability is critical.’

Dr Hester Wilson, Chair of the RACGP’s Specific Interests Addiction Medicine network, told newsGP she would support reducing restrictions on buprenorphine.

‘It makes sense from a risk profile,’ she said. 

‘It’s a strange situation when we can prescribe much higher-risk opioids like fentanyl and oxycodone, but we’re not allowed to for buprenorphine or naxolone. It’s weird, because it’s much safer.’

Dr Wilson said Australian states and territories vary widely in how restrictive they are around the drug.

‘In NSW, any doctor can commence and prescribe for up to 20 people on buprenorphine/naxolone. But in Western Australia, forget about it – you can’t do it without doing training. Their access to treatment is very highly controlled, and so is Tasmania,’ she said.

Methadone is the most common drug prescribed for opioid pharmacotherapy in Australia, according to 2017 AIHW statistics, accounting for three-fifths of Australia’s almost 50,000 people on pharmacotherapy for opioid dependence.
 
When provided in medium to high doses, methadone and buprenorphine appear equally effective at retaining patients in treatment, according to a 2014 Cochrane review.
 
But Associate Professor Nielsen said that buprenorphine has less risk of causing overdose, given it is a partial opioid agonist, while methadone is a full agonist.
 
‘In the first two weeks of methadone treatment, there are higher rates of mortality because people are overshooting their dose,’ she said. ‘Buprenorphine has a ceiling on its respiratory depressant effect, so it doesn’t lead to an overdose state when used on its own.’
 
Associate Professor Nielsen believes the drug is also less stigmatised than methadone.
 
‘Methadone can have negative associations [for patients], whereas buprenorphine doesn’t have that baggage,’ she said.

Dr Wilson agrees and believes making buprenorphine more widely available is only part of the issue, with structural impediments to access – including stigma, education and dosing support – also a key factor.

‘Part of the issue is that we developed strict controls for methadone, which is a far more dangerous opioid, and applied that same formulation to a much less dangerous medication,’ she said.

‘The French experience showed that overdose deaths dropped – so it’s a harm-minimisation approach, because it’s a safer medicine than other opioids.’

buprenorphine deaths opioid pharmacotherapy