Author: Ruiqi Tang
Edited by: William Dean, Sophie Hill, and Noah Steinfeld
Less than 35% of the 2.3 million people with opioid misuse in the United States receive treatment. Opioids are a class of drugs that mask pain by interacting with opioid receptors in the brain, producing pleasurable sensations. These “euphoric” feelings can lead to addiction when patients begin taking opioids for non-medical use. Despite the growing crises of opioid addiction, there is a dire shortage of physicians approved to prescribe a medication approved by the Federal Drug Administration (FDA) for treating opioid addiction: buprenorphine. Buprenorphine works by binding to opioid receptors in the brain, but unlike opioids, its sedating effects are relatively lower and it is frequently co-formulated with another drug (naloxone) to prevent overdose. Despite its safety advantages in suppressing withdrawal symptoms, physicians must undergo additional training to obtain a U.S. Drug Enforcement Agency (DEA)-issued waiver in order to prescribe buprenorphine for opioid addiction–a restriction that does not exist for opioid medications like oxycodone that have a greater risk of adverse outcomes.
There are currently three FDA-approved medications for treating opioid addiction: buprenorphine, methadone, and naltrexone. Methadone can also effectively improve withdrawal symptoms, but due to its potency, methadone treatment for opioid addiction is limited to specialty clinic settings to better control dosage. Naltrexone is an entirely different type of drug; it completely blocks opioid receptors from the effects of opioids instead of activating it. Patient taking naltrexone will neither feel the euphoric effects of opioids nor receive relief from withdrawal symptoms because the brain’s opioid receptors are not activated. Ineffective management of withdrawal symptoms can lead to poor patient compliance, so naltrexone is rarely used as the first-line treatment for opioid addiction. All three medications can be used as part of evidence-based medication assisted-treatment (MAT), which is considered to be the gold standard of addiction care. MAT stands in contrast with the more traditional abstinence-based approach, where individuals cannot rely on medications to alleviate their withdrawal symptoms as they wean off their physical dependence to opioids.
Unlike methadone, buprenorphine can be prescribed and dispensed in outpatient settings, though only by eligible health care providers. They must meet certain qualifications to receive a DEA-issued waiver, represented by a prescriber identification number that starts with the letter “X.” The “X waiver” requirement, established by the Drug Addiction Treatment Act of 2000, was intended to expand access to opioid addiction treatment by providing an alternative to methadone. Opioid-related deaths, however, have continued to climb in the subsequent decades because the demand for treatment quickly outpaced the supply of prescribers. What was originally a show of leniency has now become an onerous requirement that hinders physicians’ ability to treat patients with opioid addiction.
Acceptance of buprenorphine-based treatment for opioid misuse is further complicated by the stigma of addiction. Many believe that treating opioid use disorder with buprenorphine is akin to replacing one opioid with another. This is not true; buprenorphine binds only partially to opioid receptors, thereby producing a less powerful effect than medications like methadone and oxycodone. Others express concern over diversion to non-medical use and abuse of buprenorphine, but the majority of illicit buprenorphine use is for treatment of withdrawal symptoms by patients who could not obtain a prescription. Meanwhile, prescription pain medications continue to be readily prescribed in the U.S. despite their addictive potential and overdose risks.
Recognizing the need for MAT and measures to prevent overdoses, legislation and institutions are making changes. Congress passed the SUPPORT for Patients and Communities Act in October 2018 to expand treatment through a variety of measures, such as giving buprenorphine prescribing privileges for non-physicians (i.e. physician assistants and nurse practitioners) and increasing the maximum number of patients to whom providers can prescribe buprenorphine. Funding has also been made available for medical schools to implement curriculum changes focused on training students to fulfill the waiver training requirements by graduation. Several medical schools, including the University of Michigan, have already begun incorporating this training into their curriculum to increase the number of buprenorphine prescribers. Despite these efforts, many people in the U.S.—particularly those in rural counties—still do not have access to waivered providers. The demand is too great and existing efforts rely on incremental increases in prescribing capacity.
To more directly tackle the problem, there is a growing movement calling for looser buprenorphine regulations and eliminating the X waiver entirely, which would allow all medical providers to prescribe buprenorphine for addiction treatment. The implementation of a similar policy in France lead to a 79% decrease in opioid overdoses in three years after relaxing buprenorphine prescription regulations. This program has allowed for greater integration of MAT into primary care, which, in the U.S., would permit more than 320,000 primary care providers to offer buprenorphine-based addiction treatment. In May 2019, a bipartisan bill was introduced to the U.S. House of Representatives to do just that. The bill, called Mainstreaming Addiction Treatment Act of 2019, would also require the Secretary of Health and Human Services to launch a national campaign to educate practitioners about substance use disorder and encourage them to integrate addiction treatment into their practices. But so far, movement on this bill has stalled.
While safe and effective treatment for opioid addiction exists, it continues to be out of reach for the majority of those who need it in the U.S. Even as COVID-19 dominates news cycles and strains the health care system, the opioid epidemic will continue to rage on in the background. Unless we commit to changing the stigma of addiction and expanding access to MAT, opioid-related deaths will remain an epidemic long after the pandemic wanes.
Ruiqi is a first-year medical student interested in community mental health and health disparities. Prior to medical school, she worked in Supportive Housing Programs and a homeless health center in Oakland, California for three years.