tag:blogger.com,1999:blog-7772182113499451603.post4649837948413586793..comments2024-03-27T10:50:53.692-05:00Comments on Real Psychiatry: Policy Makers Are Always The Weakest Link In HealthcareGeorge Dawson, MD, DFAPAhttp://www.blogger.com/profile/03474899831557543486noreply@blogger.comBlogger2125tag:blogger.com,1999:blog-7772182113499451603.post-71875599279986200232019-06-23T11:59:43.005-05:002019-06-23T11:59:43.005-05:00There are now several medications with REMS requir...There are now several medications with REMS requirements that are more difficult hurdles than a few hours of training. They can only be administered in a certain context and in the case of some like Xyrem - there is only one pharmacy in the US that is designated to dispense them. In that case the pharmacist decides on whether or not it gets dispensed based on a detailed telephone interview with the patient.<br /><br />Most REMS procedures are unknown to non-specialists that prescribe the medications. In the case of buprenorphine if prescribing is being scaled up and generalists are expected to participate familiarity with safest possible use and the suggested REMS for Suboxone would seem like a minimum requirement but I can see how some would view that as relative. The best example that I can think of is the demonstration in the European literature that methadone maintenance can be an office based practice, although I can't imagine that the generalists in that study had an average knowledge about prescribing methadone. <br /><br />From a political perspective it doesn't cost politicians anything to get rid of the course requirement and that makes it more likely that it will happen. But as noted in my post - it will take more than that. We already have many physicians and providers with their X waiver are not prescribing to capacity and the survey by Hun and Dunn suggests that needing more CME or being paired with a more experienced provider was one of the significant reasons:<br /><br />https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5524453/<br /><br />I agree with the idea that it can be part of physician training. I would back it up to the third year in medical school or even the pharmacology course during the basic science years.<br /><br />I can recall learning about opioids in the second year of medical school and standing in a neurosurgery clinic the next - handing out prescriptions for hundreds of opioids several times a day (all countersigned by the appropriately licensed attending physician of course). <br /><br />The 20+ year history of the opioid epidemic suggests that politics and advertising can cancel out even the best medical training.George Dawson, MD, DFAPAhttps://www.blogger.com/profile/03474899831557543486noreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-11019987828605201872019-06-23T06:01:18.982-05:002019-06-23T06:01:18.982-05:00As a bupruenorphine-certified young psychiatrist I...As a bupruenorphine-certified young psychiatrist I feel strongly that the training requirement must be eliminated. The main reason is that physicians do not need any additional training to prescribe the myriad of opioids that cause iatrogenic use disorders and requiring additional training for buprenorphine implies that it is somehow higher risk than all the other drugs physicians prescribe. There is not another medication I'm aware of in all of medicine with a similar requirement. I'm not implying that MAT is low risk, I'm just saying that buprenorphine is singled out among all medications and I think we should carefully consider why. Unless one thinks that each class of potentially dangerous meds should require it's own 8h course and certification process. I can't imagine cardiology, heme/onc or any other specialty agreeing to this. I think it's a shame that many psychiatrists accept this and its influenced more by the stigma of addition and mental illness more than safety data IMO. You could argue that it's a relatively small administrative hurdle but given the number of other administrative hurdles in today's practice climate, rampant burnout etc I really think we need to eliminate it if we are serious about expanding MAT. It's insulting to our specialty and restricts care for our patients.<br /><br />Additionally, maybe the courses vary but I took it winter of PGY2 year an there was no new to me information contained in it. That's a reflection of how basic the information was, not how advanced I was at the time. <br /><br />I hope this doesn't come across as too harsh. I think there's a lot of good information in this post and blog in general that I've enjoyed reading over the past few years. <br /><br />Sophia <br /><br />https://www.sophiakoganmdphd.comSophiahttps://www.blogger.com/profile/10314471492289828705noreply@blogger.com