More doctors can now prescribe buprenorphine to opioid users. Will it help?

BALTIMORE — Buprenorphine, a drug to treat opioid addiction, has quietly stabilized Randall Lambert’s drug use over the past 15 years, even as chaos surrounds him. He cycled in and out of rehab facilities and prison, but the buprenorphine he took reduced his heroin craving and kept him from withdrawal. He is now sober, living in a rehab facility and nurturing a relationship with his three children and his mother.

“I had to be rebuilt several times,” Mr. Lambert, who works at a rehab site overseeing medications for other residents, said on a recent afternoon. But buprenorphine, he said, “got me to a place where I was 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 removed a special licensing requirement known as the “X exemption”. 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 drugs.

Hundreds of thousands of providers have become newly eligible to treat opioid users with it, a move President Biden celebrated in his State of the Union address last month.

Mr. Biden spoke at a desperate moment in the country’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 only a modest percentage of Americans who regularly use opioids receive treatment. .

But addiction experts warn that lifting the buprenorphine ban may not be a panacea. Those experts say the health system’s gap in reaching opioid users remains huge, despite a sharp increase in overdose deaths in recent years.

Medical schools do not include opioid addiction in their curriculum, leaving young doctors without specific training in treating drug users. Some health providers with busy medical practices are mindful of the mental and social needs of opioid users. Treatment for black and Hispanic people is often spotty and short. And even when someone gets a prescription for buprenorphine, some pharmacies may not dispense it.

“For improving access, it may be that removing the X exemption helps, but it may not be enough,” said Dr. David Filin, an addiction therapist at the Yale School of Medicine, who followed the X exemption. Have trained other doctors to do the same. The risk, he said, was “access without quality”.

Buprenorphine is an opioid commonly taken at home to reduce cravings and prevent 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, director of the White House’s Office of National Drug Control Policy, said in an interview that about 130,000 health providers had X exemptions at the end of last year, when the rule was scrapped. Now, he said, two 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 specialized clinics to obtain methadone doses, even if they are given limited take-home facilities.

Tonia Stevens, a retired custodian, takes two long bus rides five days a week to her methadone treatment from an addiction center in Baltimore operated by the University of Maryland.

The effort required to organize her life around addiction treatment frustrated her. “The more you try, the more doors are closing for you,” she said.

The use of both drugs is not equally embraced. Some treatment programs and conservative lawmakers have been reluctant to promote buprenorphine, viewing it as swapping one opioid for another. Some lawmakers have suggested that removing the X exemption requirement could lead to poorly trained physicians making uninformed decisions or the misuse or sale of the drug.

Representative Diana Hershberger, Republican of Tennessee and a pharmacist, warned at a hearing last month that some people heat up strips of buprenorphine and inject them, a rare and ineffective method health experts say.

As of December, doctors who went through the process of getting an exemption still faced a limit on how many patients they could treat at a time. Addiction experts said barriers that may seem daunting to clinicians unsure about working with opioid users serve as a permissive structure to avoid that task in their practice. Many Americans lived far from doctors who had exemptions.

Patients have also faced changing rules about how they can get the drug. During the public health emergency for the pandemic, the federal government has initially allowed the prescribing of buprenorphine over video or phone visits.

Mr. Lambert, who lives in Hagerstown, MD, renewed his prescription last month through a telehealth appointment with the Baltimore Addiction Center. As the appointment began, Dr. Omar Farooq erased his X exemption as a computer — a moment that explained the changes from federal law.

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 do not have an in-person appointment, a change that may restrict access. Medicine. Missed doses of the treatment may cause withdrawal and increase the risk of recurrence.

The University of Maryland’s Addiction Center, next to the B&O Railroad Museum, outlines the range of help for opioid users. 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 rest or find accommodations. Can get help from the staff.

Across the street stands a reminder of a city’s vulnerability battling the deadly spread of fentanyl: a building with missing and boarded-up windows, next to which people sometimes sell or consume drugs.

Addiction experts say eliminating the waiver requirement could redirect patients from specialty settings to primary care, which lack buprenorphine-prescribing physicians.

White House drug chief Dr. Gupta said, “It’s no different than working with someone who has diabetes and can’t control their blood sugar, or who has trouble managing their diet and high blood pressure.” Happening.”

Last week, Baltimore resident Sandy Ford renewed her Suboxone prescription at a primary care appointment with Dr. Aaron Greenblatt, a family physician at the University of Maryland. Ms. Ford had received primary care at the clinic for other health problems, including back and leg pain and loss of appetite.

With her drug use on buprenorphine under control, she was looking for a job.

“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 dispensing buprenorphine now that the waiver requirement has been removed. Obstetricians and gynecologists would also benefit from the loosened regulations, as there has been a rise in opioid use disorder among pregnant women 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 be receiving more medication.

Some doctors are still hesitant to open their practices to opioid treatment, seeing it as a complicated undertaking that could detract from the attention of other patients. Dr. Nell Tracibule, 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 many opioid users. But without X Waiver, she relied on pain management specialists to treat her.

“I certainly wouldn’t want that to be the main reason patients visit me,” she said of prescribing buprenorphine.

Megan Wojtko, chief clinical officer for Choptank Community Health, a network of community clinics in rural Maryland, said that while some of her new physicians had X waivers and could treat opioid users with buprenorphine before December, many of the clinics The doctors didn’t.

“It’s just one more thing at a time when we’re doing multiple things,” she said. Eliminating the need for waivers, he said, “will work in the long term, but we need a lot of external and internal resources to reduce the stigma and give the team the training and structure they really need.”

Dr. Elizabeth Salisbury-Afshar, an addiction therapist at the University of Wisconsin-Madison, who has trained doctors in prescribing buprenorphine, said there are “so many concerns of lack of health care in rural areas” that demand for health providers has to be met. would be difficult to meet, “because there are not enough physicians.”

The Yale physician, Dr. Filin, said that in training sessions held for X-waivers, some doctors felt the stigma attached to the drug.

“They thought it was fine to provide treatment for six to eight months, but nobody should be on this drug forever,” he said. “There will be arbitrary limits.” He added that “patients would struggle” if they were weaned off buprenorphine.

Results appear at the Baltimore Center. Charlene Williams was there last week drinking coffee while her daughter played Jenga next to her. She went there for her methadone dose. Ms. Williams was once homeless, sleeping in her car and showering in Popeyes’ bathroom.

She liked taking buprenorphine at the start 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 get her medication. She wanted to be present in his 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.”