Surely the most grim and frustrating aspect of the opioid epidemic is that thousands of Americans are now dying from a disease that we know how to treat.
Only about 20 percent of people suffering with opioid addiction are getting treated with any of the three FDA-approved medications for that lethal disease—one that, according to the CDC’s latest figures, claimed nearly 50,000 lives over the 12 months ending in November, 2017.
Just two weeks ago NIDA director Nora Volkow observed: “We now possess effective treatment that could … save many lives, yet tens of thousands of people die each year because they have not received these treatments.”
“We have to make it easier to obtain buprenorphine than to get heroin and fentanyl.”
This week, three opinion pieces in the New England Journal of Medicine, written by some of the most eminent figures in the field, tackled the vexing question of how to get those medications—buprenorphine, methadone, or naltrexone—to more of the people who need them.
Though the articles make a number of recommendations, the highlights are these three.
1. Lift restrictions on prescribing buprenorphine
“We have to make it easier to obtain buprenorphine than to get heroin and fentanyl,” write Sarah Wakeman, MD, and Michael Barnett, MD.
(Wakeman is the medical director of the Substance Use Disorders Initiative at Massachusetts General Hospital, and Barnett is a professor at the Harvard T.H. Chan School of Public Health.)
One key step toward achieving that goal, they argue, would be to lift the regulatory restrictions that currently bar most general practitioners from prescribing that medication.
“We need to mobilize 320,000 primary care physicians,” they argue.
For a number of reasons, buprenorphine (often in the branded preparation known as Suboxone) is the most attractive treatment drug for most patients with opioid addiction today.
Yet often a regulatory hurdle blocks them from getting it. Since 2000, federal law has required that in order for a physician to prescribe buprenorphine as an addiction treatment (though, oddly enough, not as a painkiller), the doctor must first obtain certification that he or she has completed an eight-hour training program.
Unfortunately, only about 50,000 physicians in the U.S. have jumped through that hoop—about five percent. (As we have pointed out before, only 52 percent of counties in the US have a single practitioner qualified to prescribe it, and fewer than 40 percent of rural counties have one.)
Wakeman and Barnett argue that it’s past time to lift this outdated restriction. Administering buprenorphine is no more complex a task than administering a great many other medications PCPs regularly prescribe, they contend. In addition, they add, the very existence of the certification requirements tends to intimidate general practitioners into mistakenly assuming that it must be.
2. Hub-and-spoke treatment
In a second of the trio of New England Journal of Medicine articles, a team from Johns Hopkins University also urges that we “expand the pool of clinicians who treat” opioid addiction. But their focus is different.
“As currently delivered,” they stress, “this treatment is not fully living up to its promise.” (The authors are Brendan Saloner, Ph.D., Kenneth Stoler, MD, and Caleb Alexander, MD, from the Johns Hopkins School of Medicine and the JHU Bloomberg School of Public Health.)
Though the authors urge a variety of reforms—touching on the practices of both insurers and health care systems—one measure would facilitate wider distribution of buprenorphine without requiring an act of Congress.
Hub-and-spoke systems have been proven successful in Vermont and several other locales, they point out. What that means is that a patient’s routine addiction treatment is managed by a primary care physician (the “spoke”) while a more specialized community health center “hub,” equipped with addiction specialists, is available to take over from or advise the generalist when needed.
The support of the hub specialists makes general practitioners more willing to take on the responsibility of playing a role in addiction treatment to begin with, and, hence, more willing to devote the time necessary to get certified to prescribe buprenorphine.
3. Allow primary care physicians to prescribe methadone
According to another federal law, enacted in 1974, doctors generally cannot prescribe or administer methadone in their offices at all.
Methadone can only be administered by highly regulated clinics and—in the early stages of treatment, at least—it can be consumed only on the clinic premises.
For many, traveling to a methadone clinic is inconvenient and stigmatizing, and for patients in rural areas, the time and cost of doing so may be prohibitive.
So why not lift that law, too? Three luminaries from Boston University urge that approach in a third New England Journal article. (They are Jeffrey Samet, MD, the chief of general internal medicine at Boston Medical Center; Michael Botticelli, the executive director of the Grayken Center for Addiction and the former director of ONDCP under President Obama; and Monica Bharel, MD, the commissioner of the Massachusetts Department of Public Health.)
At first, it sounds like a radical suggestion. Viewed in an international context, however, it suddenly sounds mundane and commonsensical.
“Methadone has been available by prescription in Australia since 1970, in Great Britain since 1968, and in Canada since 1963,” the authors write. “[I]n all these places it is the most commonly prescribed treatment for opioid use disorder,” he authors write. (The same writers published a shorter, more accessible version of their recommendations in STAT.)
There’s one final point voiced this week that seems worth including. It’s that of non-physician Patrick Skerrett, the editor at STAT’s opinion section.
The title of his article sort of says it all: “Hey, doctors: Why aren’t you stepping up to treat people with opioid addiction?”
Yes, that’s easy for him to say—he’s not a physician. And that’s easy for me to say for the same reason. But I think he’s on to something.
Because, let’s face it, it’s not just eight hours of training that’s stopping most doctors from getting certified. You can do the training online at your convenience; most physicians could work it in if they wanted.
A bigger factor has to be that a lot of doctors just don’t want “addicts” in their waiting rooms. They’re afraid they’ll lie and steal and things like that.
“But a lot of these fears are not based on reality,” addiction psychiatrist Adam Bisaga told me a couple months ago when I interviewed him about his book, Overcoming Opioid Addiction. “This is an idea of addiction perpetuated in popular culture. …. My experience is that physicians who are able to overcome this and open their practices to those patients actually are blown away by how different the reality is from what they expected. …
“You can have a huge impact on people’s lives,” he continued. “Exactly because you are the doctor that gives this patient a different experience than he has received from the rest of the medical care, where they are hated, shunned, rejected.”