Dr. Hyman raises some important issues about the treatment of opioid dependence and the role of primary care physicians in treatment. Concerning the treatment of short-term withdrawal (detoxification), it is important to keep in mind that detoxification refers specifically to the process of safely and comfortably bringing a patient from a drug-using to a drug-free state. In the case of heroin dependence, this typically involves a relatively brief period and should be viewed as an initial step down a long road of treatment. Detoxification must always be followed by a referral to ongoing substance abuse treatment for prevention of drug use relapse. While short-term withdrawal treatment is relatively straightforward, the treatment that follows is much more challenging.

We have also found that health plans are frequently unwilling to support detoxification, on either an inpatient or outpatient basis. Thus, it is not surprising to find that hospitals and treatment programs providing these services are scarce. We agree that primary care physicians need to be adept at managing withdrawal therapy for both inpatients and outpatients. In our paper, we describe treatment approaches, some of which may apply to the primary care setting.

Buprenorphine has been shown to be effective for treating opioid dependence, including opioid detoxification (1) and opioid maintenance treatment (2). Physicians considering the use of buprenorphine for detoxification should be aware, however, that buprenorphine has not been approved by the Food and Drug Administration for treatment of opioid dependence. In addition, the use of any opioid medication for the outpatient management of opioid dependence is currently restricted primarily to federally licensed treatment programs. Thus, established protocols for outpatient treatment using opioid medications are currently not available for use by primary care physicians. Until the Food and Drug Administration approves buprenorphine for detoxification treatment and federal restrictions on how and where opioid medications can be used by physicians are changed, primary care physicians are largely restricted to using nonopioid approaches, such as clonidine, when providing outpatient withdrawal therapy for opioid-dependent patients (3). Current federal initiatives, if enacted, may allow more active participation of office-based physicians in the treatment of opioid dependence in the future (4). In October 2000, Congress passed and the President signed The Drug Addiction Treatment Act of 2000, which will allow qualifying physicians to prescribe schedule III, IV, and V medications approved for detoxification and maintenance treatment of opioid dependence to their opioid-dependent patients. If, in the future, buprenorphine or other medications are approved for this indication and are scheduled in this manner, office-based physicians will be able to provide treatment for opioid dependence under the new law (4).

While there are limited data on treatment approaches that primary care physicians can use for outpatient opioid detoxification (3), no specific information is yet available on the extent to which primary care clinicians provide these treatments. Future research should examine trends and treatment practices as the role of primary care physicians as providers of detoxification and other substance abuse treatments evolves in the changing health care environment.