Policy Goal: This bill would add buprenorphine services to the list of Drug Medi-Cal services, provided the buprenorphine services are either administered by a licensed narcotic treatment program or ordered or prescribed by a physician who complies with federal requirements.
Problem: Currently, buprenorphine is not on the list of Drug Medi-Cal services and the Department of Alcohol and Drug Programs is not required to come up with a dosing fee schedule. The bill would also provide that for purposes of establishing the dosing fees, the Department is required to include comprehensive services that include physician and medication services.
In October 2002, the Food and Drug Administration (FDA) approved buprenorphine for use in opioid addiction treatment. Buprenorphine is an opioid replacement (like methadone). Buprenorphine has a low rate of diversion (it is usually combined with naloxone to reduce its diversion potential) and has other advantages over methadone for many patients. Buprenorphine has a better safety profile in cases of over-dosing than methadone. The federal government has passed legislation that allowed physicians who meet certain requirements to prescribe buprenorphine in their office-based practice.
Argument: There is a need to increase the ability of Californians to obtain treatment for opiate addiction. Prescription opioid abuse has been on the rise in the US. SAMHSA statistics show that around 5% of Californians over the age of 12 have participated in non-medical use of prescription pain relievers, and estimate that 252,000 persons meet the DSM criteria for abuse/addiction to pain relievers in the Pacific states.[1] Since 1965 numerous studies have shown that narcotic replacement therapy has been shown to reduce mortality[2], lower criminality, enhance functionality[3], and to reduce the incidence of seroconversion to HIV.[4] In many parts of the state there are not licensed narcotic treatment programs furthermore in office-based treatment opioid-dependent patients may receive opioid pharmacotherapy treatment with their own physician in a familiar setting integrated with their medical and psychiatric care.
Evidence: The National Institute of Health consensus statement of 1997 defines opioid addiction as a chronic disease, and calls for increased access to long-term treatments.[5] The World Health Organization also supports maintenance pharmacotherapy as a way to save lives and prevent HIV transmission among persons who are opioid dependent, and has declared buprenorphine to be an ‘essential medication.[6]
Safety and effectiveness for long-term use were shown by the initial US clinical trials of sublingual buprenorphine and buprenorphine/naloxone.[7] These studies showed excellent retention in treatment and reduction in opioid positive urine tests, results comparable to therapeutic doses of methadone maintenance. Extending after the initial clinical trials which led to FDA approval of sublingual buprenorphine in 2002, positive reports from long-term use in office-based and primary care private practice settings of up to four years of maintenance are now seen in the US.
Solution: AB 417 is necessary to improve access to substance abuse treatment.
-------------------------------------------
[1]Colliver, J.D., et al., Misuse of prescription drugs: Data from the 2002, 2003, and 2004 National Surveys on Drug Use and Health (DHHS Publication No. SMA 06-4192, Analytic Series A-28). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies. 2006. p. http://oas.samhsa.gov/Prescription/Ch7.htm.
[2]Gronbladh, L., L.S. Ohlund, and L.M. Gunne, Mortality in heroin addiction: impact of methadone treatment. Acta Psychiatr Scand, 1990. 82(3): p. 223-7.
[3]Ball, J.C. and A. Ross, The Effectiveness of Methadone Maintenance Treatment. 1991, New York: Springer-Verlag. 283.
[4]Ball, J.C., et al., Reducing the risk of AIDS through methadone maintenance treatment. J Health Soc Behav, 1988. 29(3): p. 214-26.
[5] NIH-CDC, Effective medical treatment of heroin addiction. NIH Consensus Statement. 1997, National Institutes of Health: Bethesda, MD
[6]Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention: position paper / World Health Organization, United Nations Office on Drugs and Crime, UNAIDS. 2004, WHO.
[7] Johnson, R.E., M.A. Chutuape, and e. al, A Comparison of Levomethadyl acetate, Buprenorphine and Methadone for Opioid Dependence. NEJM, 2000. 343(November 2): p. 1290-1295.
