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News from Annals of Family Medicine January/February 2015

Few Trained to Provide Treatment for Opioid Use

Amid rising rates of opioid use disorder and related unintentional lethal opioid overdoses, particularly in rural areas of the United States, researchers examine the distribution of physicians with Drug Enforcement Administration waivers to prescribe buprenorphine-naloxone, an effective treatment for opioid use disorder. Analyzing data for physicians on the DEA’s DATA Waived Physician List as of July 2012, they find only 2.2 percent of had obtained the waivers required to prescribe buprenorphine. Notably, 90 percent of those physicians were practicing in urban counties, leaving the majority of U.S. counties (53 percent) – most of them rural – with no physician who could dispense buprenorphine. Although are the predominant providers of health care in rural America, very low percentages of family physicians and general internists (3 percent) had obtained a DEA waiver. Most U.S. counties, therefore, had no physicians who had obtained waivers to prescribe buprenorphine-naloxone, resulting in more than 30 million persons who were living in counties without access to . Psychiatrists represented the largest group of physicians who had obtained waivers (42 percent), and most of them practiced in urban areas. The relative paucity of rural physicians trained to provide office-based treatment of opioid use disorder, the authors conclude, is a major barrier to office-based outpatient treatment for opioid use disorder.

Geographic and Specialty Distribution of US Physicians Trained to Treat Opioid Use Disorder
By C. Holly A. Andrilla, MS, et al
University of Washington School of Medicine, Seattle

Two Systematic Reviews Summarize Efficacy of Different Pharmacotherapy and Psychotherapy Treatment Options for Depression in

A systematic review of randomized trials investigating the efficacy and acceptability of different pharmacological treatments for depression in primary care finds that tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) have the most solid evidence base for being effective in the primary care setting, but with a small effect size compared with placebo. Analyzing data from 66 studies involving 15,161 patients, researchers found that TCAs and SSRIs, as well as serotonin-noradrenaline reuptake inhibitors (SNRI), low-dose serotonin antagonist and reuptake inhibitors (SARI) and hypericum extracts are effective for the treatment of acute depression, with estimated odds ratios between 1.69 and 2.03. They found no statistically significant differences between the drug classes. While hypericum, reversible inhibitors of monominoxidate A (rMAO-A), nor-adrenaline reuptake inhibitors (NRI), noradrenergic and specific serotonergic antidepressive agents (NaSSA), SNRI and SARI showed some positive results, the authors emphasize that limitations of the currently available evidence make difficult a clear recommendation on their place in clinical practice. Compared with other agents, rMAO-A and hypericum extracts were associated with significantly fewer dropouts because of adverse effects. The authors call for future research prioritizing large, long-term, pragmatic trials and observational studies addressing clinically relevant questions, such as the best management of mild-to-moderate depression and comparison of pharmacological and psychological treatments under conditions of routine care and stepped-care strategies.