Two decades ago, as opioid overdose deaths rose steadily, the federal government restricted access to buprenorphine. This medication is what addiction experts consider the gold standard in treating opioid use disorder patients. It has been proven in study after study. Helps people continue their addiction treatment While Reduce the chance of an overdose And Death.
Prescription of the medicine required a eight-hour training for clinicians. They were limited in their ability to treat patients and required special records. They were issued a Drug Enforcement Administration registration number beginning with X. This designation, many doctors believe, made them targets for drug enforcement audits.
“Just the act of taking care patients with substance abuse disorders made us feel dangerous,” she said. Dr. Bobby MukkamalaChair of an American Medical Association Task Force on Substance Use Disorder.
“The science doesn’t support it, but the rigamarole suggested otherwise.”
This rigamarole has mostly disappeared. Congress abolished what was known as the “X waiver” in legislation. President Joe Biden Signed late last year. This is the moment some addiction experts call a “truth-sealer moment”.
Did the X-waiver, and all the associated burdens, really explain why only 7% of U.S. clinicians were allowed to prescribe buprenorphine in the first place? They were a cover for hesitation in treating addictions, if they weren’t outright hatred for them?
Some leaders in the field are optimistic that the X-waiver can be removed and buprenorphine access will increase. One study starting in 2021 Studies have shown that opioid agonists such as buprenorphine and methadone reduce the risk of death for those suffering from opioid dependence by half. This opioid produces weaker effects than heroin and fentanyl, which reduces the desire for these deadly drugs.
The nation’s drug czar Dr. Rahul GuptaAccording to a report, getting rid of the XWaiver would prevent millions of deaths.
Gupta stated that the impact of this “will be felt for many years to come.” “It’s a historic shift that I honestly could only dream of.”
Gupta and other visionaries envision obstetricians prescribing buprenorphine for their pregnant patients, infectious diseases doctors adding it to the medical toolbox, as well as lots of buprenorphine-using patients when they visit emergency rooms, primary care clinics and rehabilitation facilities.
We are changing the way we think so that every moment is an opportunity to save lives and start treatment. Dr. Sarah WakemanThe medical director for substance abuse disorder at Mass General Brigham, Boston is Dr.
Wakeman stated that the clinicians she had been speaking to for the past ten years are now open to considering treating buprenorphine-dependent patients. She is aware that stigmatization and discrimination can hinder efforts to serve those who aren’t being served. A national survey was conducted in 2021. Only 22% Many people suffering from opioid addiction have received buprenorphine. Methadone.
As patients with addiction queue up to receive treatment, the test for whether or not clinicians will be more proactive is taking place in clinics and hospitals across the country. Kim, a 65-year-old woman, is one of them.
Kim’s recent trip to the Greater New Bedford Community Health Center, southern Massachusetts, began in an examination room with Jamie Simmons (a registered nurse who manages the center’s addiction treatment program, but does not have prescribing power). Kim’s first name was not to be used by KHN to avoid any discrimination relating to her drug use.
Kim shared with Simmons that she had been using buprenorphine for almost 20 years to stay away from heroin and not overdose. Kim uses Suboxone, a combination buprenorphine/naloxone that she dissolves under the tongue.
Kim stated, “It’s one of the greatest things they could have ever done.” “I don’t believe I ever had any desire to use heroin since taking them.”
Buprenorphine Although mild euphoria can be experienced and slow breathing, there is a limit to the effects. Kim and other patients may develop tolerance to the effects, but they might not feel any.
Kim stated, “I don’t get high on Suboxones.” They keep me normal.
Many clinicians are still hesitant to prescribe buprenorphine, also known as a partial opioid antagonist, to treat addiction to other deadly drugs.
Kim’s primary doctor at the hospital never applied for an X waiver. Kim moved from one treatment program and another for years, always seeking a prescription. Kim’s cravings returned after she lost her access to buprenorphine. This was especially frightening considering that heroin has been largely replaced by the powerful opioid fentanyl in Massachusetts.
Kim stated, using a slang term to describe overdosing. “That stuff is so strong, it explodes in a matter of minutes.”
Fentanyl is a fast-killing drug that can be used to kill. Benefits of buprenorphine As more people die from opioid-related diseases, the demand for other drugs to treat them has risen.
Buprenorphine can be found in a A small number of deaths from overdoses occur nationwide, 2.6%. 93% of those involved a combination of one or more drugs, most often benzodiazepines. Fentanyl can be used in 94% of overdose deaths Massachusetts
“Bottom line is, fentanyl kills people, buprenorphine doesn’t,” Simmons said.
Kim’s visit to the health center was made more urgent by this fact. Kim had taken her last Suboxone just before arriving, and her current prescription was expired.
If she didn’t take more Suboxone, her cravings for heroin would have returned within a few hours. Simmons confirmed Kim’s dose and informed Kim that her primary doctor may be willing to renew her prescription. After reviewing Kim’s latest urine test, Dr. Than Win was concerned. Win was concerned about the interaction of street drugs with buprenorphine after it showed traces cocaine, fentanyl and marijuana.
Win stated that he didn’t want his patients dying from overdose. “But I don’t like the fentanyl or a lot of the narcotics in this system.”
Kim maintained that she didn’t intentionally inhale fentanyl. She suggested it could have been in the cocaine her roommate shared with her occasionally. Kim stated that she uses Xanax for sleep. Kim’s drug use is a problem that not many primary care physicians are familiar with. Although there is overwhelming evidence to support the use of opioids to treat opioid addiction, some clinicians remain hesitant about using them.
Win was concerned about her first Suboxone prescription. Kim was able to continue taking the medication after Win agreed.
Win stated, “I wanted to make it a little easier for someone to start with,” It’s difficult for me. That’s the truth and reality.
Nearly half of providers at the Greater New Bedford hospital had an X waiver when it was still necessary. Simmons suggested that doctors treat addiction like any other disease, and that some resistance to the waiver can be attributed to stigmatization or misunderstandings about addiction.
Simmons stated, “You wouldn’t refuse to treat a diabetic patient; you wouldn’t refuse to treat a hypertensive patient.” People can’t control the fact that they have developed an addiction to opiates, alcohol, or benzos.
Looking for ways to soften stigma
While the ban on prescribing buprenorphine is no longer in effect, Mukkamala stated that the perception of the X-waiver lingers.
Mukkamala stated, “The legacy of elevating it to a level that scrutiny and caution –that has to be kind of walked back.” Education will help with that.”
Mukkamala sees potential in the next generation, of doctor, nurse practitioner, and physician assistants, who are graduates of schools with addiction training. The AMA The American Society of Addiction Medicine Online resources available for clinicians who wish to learn on their terms.
These resources might help you fulfill your needs. New training requirements For clinicians who prescribe buprenorphine or other controlled narcotics. It will be in effect from June. Details about the training have not been released by the DEA.
Training alone will not change behavior, as Rhode Island’s experience has shown.
Threefold increase in the number of Rhode Island doctors who are licensed to prescribe buprenorphine From 2016 to 2022, after the state declared Physicians in training should have an X-waiver. However, the possibility to prescribe buprenorphine did not “open the floodgates” to patients who needed it. Dr. Jody RichBrown University addiction specialist, Dr. Between 2016 and 2022, as the number qualified prescribers increased in number, buprenorphine prescriptions also increased but at a smaller percentage.
Rich stated, “It all comes down to stigma.”
He stated that the long-held resistance of some doctors to treating addiction is changing as more people become medical professionals. He said that tackling the opioid crisis cannot wait for a change in generational attitudes. Rich suggests that states use pharmacists partnered with doctors to expand buprenorphine availability. This will allow them to manage more opioid-using patients. research shows.
Wakeman suggested that clinicians who do not provide addiction care should be held accountable by quality measures linked to payments.
Wakeman stated, “We are expected to care about patients with diabetes or heart attack in a specific way. The same should be true for patients suffering from an opioid use disorder.”
It is important to monitor how often buprenorphine prescriptions are started and continued. Wakeman stated that it would be beneficial for clinics to reimburse them for staff who aren’t traditional clinicians, but are crucial in addiction care like recovery coaches or case managers.
Is the End in sight of the X-Waiver Racial Gaps
Wakeman and others are particularly interested in whether the elimination of the X-waiver can narrow racial disparities in buprenorphine therapy. The medication is More often prescribed Patients of color with private insurance or cash can receive the same treatment as those who are white. There are stark differences in race at certain health centers, where the majority of patients are on Medicaid. This would appear to give them equal access to addiction treatment.
Black patients make up 15% of the New Bedford hospital’s patients, but only 6% for those who are taking buprenorphine. It is between 30% and 23% for Hispanics. White patients comprise 61% of those who were prescribed buprenorphine by health centers, but only 36% of all patients.
Dr. Helena HansenCo-author of a book about Race and the opioid epidemicAccess to buprenorphine is not a guarantee that patients will be able to benefit.
Hansen stated that people cannot stay on lifesaving medications unless there is stability in housing, employment and social supports — the very fabric — of their communities. “That’s the area where the United States falls short.”
Hansen stated that expanding access to buprenorphine is a good idea. helped reduce overdose deaths dramatically All drug users in France are included, even those with low incomes or immigrants. Patients with opioid addiction disorder are treated in their own communities and provided with a variety of social services.
Hansen stated that “removing the X waiver” is not going to solve the opioid overdose crisis. We’d need to do more.
This article is part a partnership that also includes WBUR, NPRKHN.