The debate about lifting the patient cap — 30 or 100, depending on training — for buprenorphine is entering its second official year, with one side questioning whether physicians would be able to treat a large volume of patients and the other arguing that once patients are stable, treatment is not time-consuming. In last week’s issue, Mark Parrino, president of the American Association for the Treatment of Opioid Dependence, the trade association representing opioid treatment programs, pointed out that the guidelines for the use of medication-assisted treatment call for the use of best practices (see ADAW, Aug. 24). “If you’re treating 300 to 500 patients, how do you do this?” he asked.

“Very easily,” Stuart Gitlow, M.D., immediate past president of the American Society of Addiction Medicine (ASAM), wrote us. The letter from Gitlow continues below.

“Parrino, who is not a physician, may not realize that a typical outpatient physician can easily handle this volume of patients, and indeed, many more. Let’s look at a less stigmatized situation first: a patient presents for first-time treatment for major depression. Symptoms are significant and the patient is functionally impaired. The intake takes some time and a combination of psychotherapy and pharmacotherapy is initiated. The patient is seen frequently at first, with significant time taken at each visit. As time passes, the patient typically improves. Psychotherapy is discontinued when the patient reaches maximum improvement from that modality. Eventually, as the patient becomes symptom-free, the patient is seen annually for renewal of medication. A typical psychiatrist in long-term private practice has quite literally hundreds of such patients.

“The outpatient addiction model is quite similar. So in my practice, after nearly ten years of prescribing buprenorphine, I have roughly 90 patients who I’ve been seeing for an average of seven years. They are largely symptom-free, functional in all respects, attending twelve-step meetings, demonstrating negative urine drug test results, and no longer in need of any intensive care. I see many of them every 3 to 4 months to renew their medication, just as I do my patients with well-treated schizophrenia, bipolar disorder or anxiety disorder. My total number of patients in my outpatient practice is just under 1000, and since I’ve been in practice for 22 years, the vast majority of these patients are stable and symptom-free. The bulk of my time, however, is spent with the minority: the patients more recently admitted into the practice.

“So when Parrino asks how could one treat 300 to 500 patients, the answer is: very easily. In fact, the number could be significantly higher. Could I, a single private practice physician, handle 300 to 500 NEW patients all at once? Of course not. There aren’t the hours in the day to do that. But that’s not the question. The question is whether a typical practice could accommodate greater than 100 patients taking buprenorphine. We could indeed, so long as we follow a typical course of a private practice, where new patients are gradually added as existing patients require diminishing amounts of treatment intensity. The concept of a limit is foolish; we don’t have a limit with schizophrenia, a disease that arguably requires even more complexity of services over a more extended time period than addiction. Why would we possibly have a limit with addictive disease treatment?”

Legislation has been proposed that would lift or eliminate the cap. SAMHSA has not indicated which way it will go but has provided information to Sylvia Burwell, secretary of the Department of Health and Human Services, on the issue. Stay tuned.