More doctors can now prescribe a key opioid treatment. Will it help?
Buprenorphine is an opioid usually taken at home that eases cravings and prevents withdrawal.
Buprenorphine, a medication to treat opioid addiction, has quietly stabilized Randall Lambert’s drug use over the past 15 years, even as chaos surrounded him. He cycled in and out of rehab facilities and jail, but the buprenorphine he took eased his heroin cravings and kept him from withdrawal. He is now sober, living in a rehab facility and nurturing relationships with his three children and his mother.
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“I’ve had to rebuild so many times,” Lambert, who works at the rehab site supervising medications for other residents, said on a recent afternoon. But buprenorphine, he said, “got me to a place where I got clean.”
Now buprenorphine, once highly restricted, is available to far more doctors to prescribe for patients, the result of a significant change in federal drug policy that scrapped a special licensing requirement known as an “X waiver.” In December, Congress approved the change as part of a government spending package, dramatically expanding the pool of physicians and health workers who could prescribe the medication.
Hundreds of thousands of providers have become newly eligible to treat opioid users with it, a move President Joe Biden celebrated in his State of the Union address last month.
Biden spoke at a desperate moment in the nation’s overdose epidemic. While more than 100,000 people die each year from drug overdoses in the United States, many of them from fentanyl, addiction physicians say that only a modest percentage of Americans who regularly use opioids receive treatment.
But addiction experts warn that lifting the buprenorphine restrictions may not prove to be a panacea. The health system’s gaps in reaching opioid users remain vast despite a catastrophic surge in overdose deaths in recent years, those experts say.
Medical schools tend not to incorporate opioid addiction in their curriculums, leaving younger doctors without specific training in treating drug users. Some health providers with busy medical practices are wary of the psychiatric and social needs of opioid users. Treatment for Black and Hispanic people is often spotty and shorter. And even when someone obtains a prescription for buprenorphine, some pharmacies may not dispense it.
“For improving access, it may be that removing the X waiver helps, but it may not be sufficient,” said Dr. David Fiellin, an addiction physician at the Yale School of Medicine who has trained other doctors pursuing X waivers. The risk, he added, was “access without quality.”
Buprenorphine is an opioid usually taken at home that eases cravings and prevents withdrawal. It is often given under the brand name Suboxone, which is administered in small orange strips under the tongue.
Access to buprenorphine could skyrocket this year. Dr. Rahul Gupta, the director of the White House’s Office of National Drug Control Policy, said in an interview that about 130,000 health providers had an X waiver at the end of last year, when the rule was abolished. Now, he said, 2 million prescribers registered with the Drug Enforcement Administration can give buprenorphine to opioid users.
Buprenorphine is one of two effective, commonly prescribed medications for opioid addiction; the other is methadone. It has significant advantages over methadone, which is so restricted that it spawned a Twitter hashtag, #freemethadone. Patients must regularly travel to special clinics to receive doses of methadone, even if they are given limited take-home privileges.
Tonia Stevens, a retired custodian, takes two long bus rides five days a week for her methadone treatment from an addiction center in Baltimore run by the University of Maryland.
The effort required to organize her life around addiction treatment left her dejected. “The more you try, the more the doors are closing on you,” she said.
The use of both medications is not uniformly embraced. Some treatment programs and conservative lawmakers have been reluctant to promote buprenorphine, seeing it as swapping one opioid for another. Some lawmakers have suggested that the removal of the X waiver requirement could lead to poorly trained physicians making uninformed prescribing decisions, or the misuse or sale of the medication.
Rep. Diana Harshbarger, R-Tenn., who is a pharmacist, warned at a hearing last month that some people heat up strips of buprenorphine and inject them, citing what health experts say is a rare and ineffective method.
Until December, doctors who went through the process of acquiring a waiver still faced a cap on how many patients they could treat with the medication at once. The obstacles could feel arduous to physicians uncertain about working with opioid users, functioning as a permission structure for avoiding that work in their practices, addiction experts said. Many Americans lived far away from doctors who had a waiver.
Patients have also faced changing rules about how they can get the medication. During the public health emergency for the pandemic, the federal government has allowed buprenorphine to be prescribed initially in video or phone appointments.
Lambert, who lives in Hagerstown, Maryland, got his prescription renewed last month through a telehealth appointment with the Baltimore addiction center. As the appointment began, Dr. Umer Farooq erased his X waiver in a computer form — a moment that encapsulated the changes from the federal legislation.
Last week, the DEA proposed that after the pandemic public health emergency is lifted in May, doctors would be limited to prescribing a 30-day supply of buprenorphine to patients who have not had an in-person appointment, a change that could restrict access to the medication. Missing doses of treatment can lead to withdrawal and elevate the risk of relapsing.
The University of Maryland’s addiction center, next to the B&O Railroad Museum, underscores the extent of the help that opioid users might need. In addition to a clinic that dispenses buprenorphine and methadone, the facility includes a primary care practice, obstetricians and gynecologists, psychiatrists, therapists and counselors, a syringe exchange program, and a common area where patients can relax or get help from employees finding housing.
Across the street is a reminder of the vulnerabilities of a city battling fentanyl’s deadly spread: a building with missing and boarded-up windows, next to which people sometimes sell or consume drugs.
Addiction experts say that the elimination of the waiver requirement may end up redirecting patients from specialized settings to primary care, which has lacked buprenorphine-prescribing physicians.
“It’s no different than trying to work with somebody who has diabetes and his or her blood sugars cannot be controlled, or somebody who’s having trouble managing their diet and high blood pressure,” Gupta, the White House drug chief, said.
Last week, Sandy Ford, a Baltimore resident, had her Suboxone prescription renewed at a primary care appointment with Dr. Aaron Greenblatt, a family physician at the University of Maryland. Ford had received primary care at the clinic for other health problems she faced, including back and leg pain and loss of appetite.
With her drug use under control on buprenorphine, she was looking for jobs.
“My thoughts are clear,” she said. “My mind is clear.”
Federally qualified health centers, where many poor and uninsured Americans receive primary care services, will become more central to delivering buprenorphine now that the waiver requirement has been lifted. The loosened regulations will also benefit obstetricians and gynecologists, as opioid use disorder among pregnant women has increased in recent years. At the Baltimore center, Dr. Eric Weintraub, a psychiatrist at the University of Maryland, oversees telehealth clinics for inmates — another key group that could receive more medication.
Some doctors are still hesitant to open their practices to opioid treatment, viewing it as a complicated undertaking that could diminish attention to other patients. Dr. Nel Trasybule, a University of Maryland primary care physician who has a busy practice with Baltimore residents of all ages and a variety of health problems, works with several opioid users. But without an X waiver, she relied on pain management specialists to treat them.
“I definitely wouldn’t want that to be the main reason patients are coming to see me,” she said of prescribing buprenorphine.
Megan Wojtko, the chief clinical officer at Choptank Community Health, a network of community clinics in rural Maryland, said that while some of her newer physicians had X waivers and could treat opioid users with buprenorphine before December, many doctors at the clinics did not.
“It’s just one more thing at a time when we’ve been doing a lot of one-more-things,” she said. Eliminating the waiver requirement, she added, “will work in the long term, but we need a lot of external and internal resources to reduce stigma and give the team the training and the structure they really need.”
Dr. Elizabeth Salisbury-Afshar, an addiction physician at the University of Wisconsin, Madison, who has trained doctors in prescribing buprenorphine, said there were “so many health shortage concerns in rural areas” that it would be hard for health providers to meet demand, “because there aren’t enough clinicians.”
Fiellin, the Yale physician, said that some doctors in the training sessions he held for X waivers perceived a stigma associated with the medication.
“They thought it was fine to provide treatment for six to eight months but that no one should be on this medication forever,” he said. “There would be arbitrary limits.” He added that “patients would struggle” if they were cut off from buprenorphine.
The consequences show up in the Baltimore center. Charlene Williams was drinking coffee there last week while her daughter played Jenga next to her. She was there for her methadone dosing. Williams was once homeless, sleeping in her car and bathing in a Popeyes bathroom.
She liked taking buprenorphine at the beginning of the pandemic, she said, before her doctor stopped working with her. While methadone eases her opioid cravings, she said she was tired of bringing her daughter to the center most days to retrieve her medication. She wanted to be present in her life.
“I stay, I hug, I hold,” she said, describing her bedtime routine with her daughter. “It makes me cry that she wants to be under me all the time.”
This article originally appeared in The New York Times.
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