{"id":909,"date":"2023-03-21T09:10:04","date_gmt":"2023-03-21T09:10:04","guid":{"rendered":"https:\/\/healthynewsusa.com\/?p=909"},"modified":"2023-03-21T09:10:09","modified_gmt":"2023-03-21T09:10:09","slug":"some-roadblocks-to-lifesaving-addiction-treatment-are-gone-now-what","status":"publish","type":"post","link":"https:\/\/healthynewsusa.com\/?p=909","title":{"rendered":"Some Roadblocks to Lifesaving Addiction Treatment Are Gone. Now What?"},"content":{"rendered":"<div>\n<p>For two decades \u2014 as opioid overdose deaths rose steadily \u2014 the federal government limited access to buprenorphine, a medication that addiction experts consider the gold standard for treating patients with opioid use disorder. Study after study shows it <a href=\"https:\/\/nida.nih.gov\/publications\/research-reports\/medications-to-treat-opioid-addiction\/efficacy-medications-opioid-use-disorder#:~:text=In%20this%20study%2C%20the%20treatment,was%20closely%20related%20to%20relapse.\">helps people continue addiction treatment<\/a>\u00a0while <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/32022884\/\">reducing the risk of overdose<\/a> and\u00a0<a href=\"https:\/\/www.nih.gov\/news-events\/news-releases\/methadone-buprenorphine-reduce-risk-death-after-opioid-overdose\">death<\/a>.<\/p>\n<p>Clinicians who wanted to prescribe the medicine had to complete an eight-hour training. They could treat only a limited number of patients and had to keep special records. They were given a Drug Enforcement Administration registration number starting with X, a designation many doctors say made them a target for drug-enforcement audits.<\/p>\n<p>\u201cJust the process associated with taking care of our patients with a substance use disorder made us feel like, \u2018Boy, this is dangerous stuff,&#8217;\u201d said\u00a0<a href=\"https:\/\/www.ama-assn.org\/about\/board-trustees\/bobby-mukkamala-md\">Dr. Bobby Mukkamala<\/a>, who chairs an American Medical Association task force addressing substance use disorder.<\/p>\n<p>\u201cThe science doesn\u2019t support that but the rigamarole suggested that.\u201d<\/p>\n<p>\n\t<iframe loading=\"lazy\" allow=\"fullscreen\" frameborder=\"0\" height=\"290\" src=\"https:\/\/www.npr.org\/player\/embed\/1159225349\/1162390621\" width=\"100%\"><\/iframe>\n<\/p>\n<p>That rigamarole is mostly gone. Congress eliminated what became known as the \u201cX-waiver\u201d in legislation President Joe Biden\u00a0<a href=\"https:\/\/www.deadiversion.usdoj.gov\/pubs\/docs\/A-23-0020-Dear-Registrant-Letter-Signed.pdf\">signed late last year<\/a>. Now begins what some addiction experts are calling a \u201ctruth serum moment.\u201d<\/p>\n<p>Were the X-waiver and the burdens that came with it the real reason only about 7% of clinicians in the U.S. were cleared to prescribe buprenorphine? Or were they an excuse that masked hesitation about treating addiction, if not outright disdain for these patients?<\/p>\n<p>There\u2019s great optimism among some leaders in the field that getting rid of the X-waiver will expand access to buprenorphine and reduce overdoses. <a href=\"https:\/\/jamanetwork.com\/journals\/jamapsychiatry\/fullarticle\/2780655\">One study from 2021<\/a>\u00a0shows taking buprenorphine or methadone, another opioid agonist treatment, reduces the mortality risk for people with opioid dependence by 50%. The medication is an opioid that produces much weaker effects than heroin or fentanyl and reduces cravings for those deadlier drugs.<\/p>\n<p>The nation\u2019s drug czar,\u00a0<a href=\"https:\/\/www.hsph.harvard.edu\/ecpe\/faculty\/rahul-gupta\/\">Dr. Rahul Gupta<\/a>, said getting rid of the X-waiver would ultimately prevent millions of deaths.<\/p>\n<p>\u201cThe impact of this will be felt for years to come,\u201d Gupta said. \u201cIt is a true historic change that, frankly, I could only dream of being possible.\u201d<\/p>\n<p>Gupta and others envision obstetricians prescribing buprenorphine to their pregnant patients, infectious disease doctors adding it to their medical toolbox, and lots more patients starting buprenorphine when they come to emergency rooms, primary care clinics, and rehabilitation facilities.<\/p>\n<p>We are \u201ctransforming the way we think to make every moment an opportunity to start this treatment and save someone\u2019s life,\u201d said\u00a0<a href=\"https:\/\/www.massgeneral.org\/doctors\/19383\/sarah-wakeman\">Dr. Sarah Wakeman<\/a>, the medical director for substance use disorder at Mass General Brigham in Boston.<\/p>\n<p>Wakeman said clinicians she has been contacting for the past decade are finally willing to consider treating patients with buprenorphine. Still, she knows stigma and discrimination could undermine efforts to help those who aren\u2019t being served. In 2021, a national survey\u00a0showed <a href=\"https:\/\/nida.nih.gov\/news-events\/news-releases\/2023\/01\/overdose-deaths-involving-buprenorphine-did-not-proportionally-increase-with-new-flexibilities-in-prescribing\">just 22%<\/a> of people with opioid use disorder received medications such as buprenorphine and\u00a0<a href=\"https:\/\/www.samhsa.gov\/medications-substance-use-disorders\/medications-counseling-related-conditions\/methadone\">methadone<\/a>.<\/p>\n<p>The test of whether clinicians will step up and if prescribing will become more widespread is underway in hospitals and clinics across the country as patients struggling with addiction queue up for treatment. A woman named Kim, 65, is among them.<\/p>\n<p>Kim\u2019s recent visit to the Greater New Bedford Community Health Center in southern Massachusetts began in an exam room with Jamie Simmons, a registered nurse who runs the center\u2019s addiction treatment program but doesn\u2019t have prescribing powers. KHN agreed to use only Kim\u2019s first name to limit potential discrimination linked to her drug use.<\/p>\n<p>Kim told Simmons that buprenorphine had helped her stay off heroin and avoid an overdose for nearly 20 years. Kim takes a medication called Suboxone, a combination of buprenorphine and naloxone, which comes in the form of thin, filmlike strips she dissolves under her tongue.<\/p>\n<p>\u201cIt\u2019s the best thing they could have ever come out with,\u201d Kim said. \u201cI don\u2019t think I ever even had a desire to use heroin since I\u2019ve been taking them.\u201d<\/p>\n<p><a href=\"https:\/\/www.samhsa.gov\/sites\/default\/files\/quick-start-guide.pdf\">Buprenorphine<\/a> can produce mild euphoria and slow breathing but there\u2019s a ceiling on the effects. Patients like Kim may develop a tolerance and not experience any effects.<\/p>\n<p>\u201cI don\u2019t get high on Suboxones,\u201d Kim said. \u201cThey just keep me normal.\u201d<\/p>\n<p>Still, many clinicians have been hesitant to use buprenorphine \u2014 known as a partial opioid agonist \u2014 to treat an addiction to more deadly forms of the drug.<\/p>\n<p>Kim\u2019s primary care doctor at the health center never applied for an X-waiver. So for years Kim bounced from one treatment program to another, seeking a prescription. During lapses in her access to buprenorphine, the cravings returned \u2014 an especially scary prospect after the powerful opioid fentanyl largely replaced heroin on the streets of Massachusetts, where Kim lives.<\/p>\n<p>\u201cI\u2019ve seen so many people fall out in the last month,\u201d Kim said, using a slang term for overdosing. \u201cThat stuff is so strong that within a couple minutes, boom.\u201d<\/p>\n<p>Because fentanyl can kill so quickly, the\u00a0<a href=\"https:\/\/www.bmj.com\/content\/368\/bmj.m772\">benefits of taking buprenorphine<\/a>\u00a0and other medications to treat opioid use disorder have increased as deaths linked to even stronger types of fentanyl rise.<\/p>\n<p>Buprenorphine is present in a\u00a0<a href=\"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/fullarticle\/2800689\">small percentage of overdose deaths<\/a>\u00a0nationwide, 2.6%. Of those, 93% involved a mix of one or more other drugs, often benzodiazepines. Fentanyl is in\u00a0<a href=\"https:\/\/www.mass.gov\/news\/massachusetts-opioid-related-overdose-death-rate-declines-15-percent-in-the-first-nine-months-of-2022#:~:text=Fentanyl%20continues%20to%20be%20the,was%20available%2C%20preliminary%20data%20show.\">94% of overdose deaths<\/a>\u00a0in Massachusetts.<\/p>\n<p>\u201cBottom line is, fentanyl kills people, buprenorphine doesn\u2019t,\u201d Simmons said.<\/p>\n<p>That reality added urgency to Kim\u2019s health center visit because Kim took her last Suboxone before arriving; her latest prescription had run out.<\/p>\n<p>Cravings for heroin could have returned in about a day if she didn\u2019t get more Suboxone. Simmons confirmed the dose and told Kim that her primary care doctor might be willing to renew the prescription now that the X-waiver is not required. But Dr. Than Win had some concerns after reviewing Kim\u2019s most recent urine test. It showed traces of cocaine, fentanyl, marijuana, and Xanax, and Win said she was worried about how the street drugs might interact with buprenorphine.<\/p>\n<p>\u201cI don\u2019t want my patients to die from an overdose,\u201d Win said. \u201cBut I\u2019m not comfortable with the fentanyl and a lot of narcotics in the system.\u201d<\/p>\n<p>Kim was adamant that she did not intentionally ingest fentanyl, saying it might have been in the cocaine she said her roommate shares occasionally. Kim said she takes the Xanax to sleep. Her drug use presents complications that many primary care doctors don\u2019t have experience managing. Some clinicians are apprehensive about using an opioid to treat an addiction to opioids, despite compelling evidence that doing so can save patients\u2019 lives.<\/p>\n<p>Win was worried about writing her first prescription for Suboxone. But she agreed to help Kim stay on the medication.<\/p>\n<p>\u201cI wanted to start with someone a little bit easier,\u201d Win said. \u201cIt\u2019s hard for me; that\u2019s the reality and truth.\u201d<\/p>\n<p>About half of the providers at the Greater New Bedford health center had an X-waiver when it was still required. Attributing some of the resistance to having the waiver to stigma or misunderstanding about addiction, Simmons urged doctors to treat addiction as they would any other disease.<\/p>\n<p>\u201cYou wouldn\u2019t not treat a diabetic; you wouldn\u2019t not treat a patient who is hypertensive,\u201d Simmons said. \u201cPeople can\u2019t control that they formed an addiction to an opiate, alcohol, or a benzo.\u201d<\/p>\n<p><strong>Searching for Solutions to Soften Stigma<\/strong><\/p>\n<p>Although the restrictions on buprenorphine prescribing are no longer in place, Mukkamala said the perception created by the X-waiver lingers.<\/p>\n<p>\u201cThat legacy of elevating this to a level of scrutiny and caution \u2014that needs to be sort of walked back,\u201d Mukkamala said. \u201cThat\u2019s going to come from education.\u201d<\/p>\n<p>Mukkamala sees promise in the next generation of doctors, nurse practitioners, and physician assistants coming out of schools that have added addiction training. The\u00a0<a href=\"https:\/\/edhub.ama-assn.org\/asam-education-cme\/interactive\/18638491\">AMA<\/a>\u00a0and the\u00a0<a href=\"https:\/\/elearning.asam.org\/addiction-education-for-prescribers\">American Society of Addiction Medicine<\/a>\u00a0have online resources for clinicians who want to learn on their own.<\/p>\n<p>Some of these resources may help fulfill a\u00a0<a href=\"https:\/\/www.deadiversion.usdoj.gov\/pubs\/docs\/A-23-0020-Dear-Registrant-Letter-Signed.pdf\">new training requirement<\/a>\u00a0for clinicians who prescribe buprenorphine and other controlled narcotics. It will take effect in June. The DEA has not issued details about the training.<\/p>\n<p>But training alone may not shift behavior, as Rhode Island\u2019s experience shows.<\/p>\n<p>The number of Rhode Island practitioners approved to prescribe buprenorphine increased roughly threefold<a href=\"https:\/\/preventoverdoseri.org\/medication-for-opioid-use-disorder-data\/\"\/>\u00a0from 2016 to 2022 after the state said\u00a0<a href=\"https:\/\/health.ri.gov\/news\/temp\/RhodeIslandsStrategicPlanOnAddictionAndOverdose.pdf\">physicians in training should obtain an X-waiver<\/a>. Still, having the option to prescribe buprenorphine \u201cdidn\u2019t open the floodgates\u201d for patients in need of treatment, said <a href=\"https:\/\/watson.brown.edu\/chrhs\/people\/josiah-rich\">Dr. Jody Rich<\/a>, an addiction specialist who teaches at Brown University. From 2016 to 2022, when the number of qualified prescribers increased, the number of patients taking buprenorphine also increased, but by a much smaller percentage.<\/p>\n<p>\u201cIt all comes back to stigma,\u201d Rich said.<\/p>\n<p>He said long-standing resistance among some providers to treating addiction is shifting as younger people enter medicine. But tackling the opioid crisis can\u2019t wait for a generational change, he said. To expand buprenorphine access now, states could use pharmacists, partnered with doctors, to help manage the care of more patients with opioid use disorder, Rich\u2019s\u00a0<a href=\"https:\/\/www.wbur.org\/news\/2023\/01\/11\/pharmacies-opioid-addiction-treatment-study\">research shows<\/a>.<\/p>\n<p>Wakeman, at Mass General Brigham, said it might be time to hold clinicians who don\u2019t provide addiction care accountable through quality measures tied to payments.<\/p>\n<p>\u201cWe\u2019re expected to care for patients with diabetes or to care for patients with heart attack in a certain way and the same should be true for patients with an opioid use disorder,\u201d Wakeman said.<\/p>\n<p>One quality measure to track could be how often prescribers start and continue buprenorphine treatment. Wakeman said it would help also if insurers reimbursed clinics for the cost of staff who aren\u2019t traditional clinicians but are critical in addiction care, like recovery coaches and case managers.<\/p>\n<p><strong>Will Ending the X-Waiver Close Racial Gaps?<\/strong><\/p>\n<p>Wakeman and others are paying especially close attention to whether eliminating the X-waiver helps narrow racial gaps in buprenorphine treatment. The medication is\u00a0<a href=\"https:\/\/jamanetwork.com\/journals\/jamapsychiatry\/fullarticle\/2732871\">much more commonly prescribed<\/a> to white patients with private insurance or who can pay cash. But there are also stark differences by race at some health centers where most patients are on Medicaid and would seem to have equal access to the addiction treatment.<\/p>\n<p>At the New Bedford health center, Black patients represent 15% of all patients but only 6% of those taking buprenorphine. For Hispanics, it is 30% to 23%. Most of the health center patients prescribed buprenorphine, 61%, are white, though white patients make up just 36% of patients overall.<\/p>\n<p><a href=\"https:\/\/socialmedicine.semel.ucla.edu\/helena-hansen\/\">Dr. Helena Hansen<\/a>, who co-authored a book on\u00a0<a href=\"https:\/\/www.ucpress.edu\/book\/9780520384057\/whiteout\">race in the opioid epidemic<\/a>, said access to buprenorphine doesn\u2019t guarantee that patients will benefit from it.<\/p>\n<p>\u201cPeople are not able to stay on a lifesaving medication unless the immense instability in housing, employment, social supports \u2014 the very fabric of their communities \u2014 is addressed,\u201d Hansen said. \u201cThat\u2019s where we fall incredibly short in the United States.\u201d<\/p>\n<p>Hansen said expanding access to buprenorphine has\u00a0<a href=\"https:\/\/ajph.aphapublications.org\/doi\/10.2105\/AJPH.2022.306763\">helped reduce overdose deaths dramatically<\/a>\u00a0among all drug users in France, including those with low incomes and immigrants. There, patients with opioid use disorder are seen in their communities and offered a wide range of social services.<\/p>\n<p>\u201cRemoving the X-waiver,\u201d Hansen said, \u201cis not in itself going to revolutionize the opioid overdose crisis in our country. We would need to do much more.\u201d<\/p>\n<p><em>This article is part of a partnership that includes\u00a0<a href=\"https:\/\/www.wbur.org\/\">WBUR<\/a>,\u00a0<a href=\"https:\/\/www.npr.org\/\">NPR<\/a>,\u00a0and KHN.<\/em><\/p>\n<aside class=\"meta-authors meta\">\n<p>\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"author-name\">Martha Bebinger, WBUR: <\/span><br \/>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/khn.org\/news\/article\/some-roadblocks-to-lifesaving-addiction-treatment-are-gone-now-what\/mailto:marthab@wbur.org\">marthab@wbur.org<\/a>,\t\t\t\t\t\t\t\t\t\t\t<a href=\"http:\/\/twitter.com\/mbebinger\" target=\"_blank\" rel=\"noopener\"><br \/>\n\t\t\t\t\t\t\t@mbebinger<\/a>\n\t\t\t\t\t\t\t\t\t<\/p>\n<\/aside>\n<section class=\"block--category-tag-list \">\n<div class=\"category-tag-list__content-wrapper\">\n<h3 class=\"block--category-tag-list__title\">\n\t\t\t\tRelated Topics\t\t\t<\/h3>\n<p>\t\t\t\t<a class=\"category-tag-list__contact-link\" href=\"https:\/\/khn.org\/contact-us\/\"><br \/>\n\t\t\tContact Us\t\t<\/a><br \/>\n\t\t<a class=\"category-tag-list__tip-link\" href=\"https:\/\/khn.org\/tips\/\"><br \/>\n\t\t\tSubmit a Story Tip\t\t<\/a>\n\t<\/div>\n<\/section><\/div>\n<p><script async src=\"\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script><\/p>\n","protected":false},"excerpt":{"rendered":"<p>For two decades \u2014 as opioid overdose deaths rose steadily \u2014 the federal government limited access to buprenorphine, a medication that addiction experts consider the gold standard for treating patients with opioid use disorder. Study after study shows it helps people continue addiction treatment\u00a0while reducing the risk of overdose and\u00a0death. Clinicians who wanted to prescribe [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":910,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[4],"tags":[],"class_list":["post-909","post","type-post","status-publish","format-standard","has-post-thumbnail","category-mental-health"],"_links":{"self":[{"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=\/wp\/v2\/posts\/909","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=909"}],"version-history":[{"count":1,"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=\/wp\/v2\/posts\/909\/revisions"}],"predecessor-version":[{"id":911,"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=\/wp\/v2\/posts\/909\/revisions\/911"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=\/wp\/v2\/media\/910"}],"wp:attachment":[{"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=909"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=909"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/healthynewsusa.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=909"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}