COMMENTARY

Buprenorphine Prescribing Restrictions Threaten Progress in the Opioid Epidemic

Hugo H. Hanson, DO

Disclosures

January 14, 2019

The American opioid epidemic is like no other drug crisis in history, spanning all ages and socioeconomic classes. We emergency physicians have unique access to patients with opioid use disorder, yet few of us are able to treat patients after an opioid-related overdose with medications such as buprenorphine in the emergency department (ED).[1,2,3,4,5,6] Federal restrictions on prescribing medication-assisted therapies (MATs) are largely to blame.

Multiple studies have shown that MATs, such as buprenorphine, significantly reduce mortality and illicit opioid use.[2] Unfortunately, many persons with opioid abuse disorder do not have access to these potentially life-saving therapies. The Drug Addiction Treatment Act (DATA), passed by Congress in 2000, limits the availability of MATs by mandating that physicians obtain a waiver from the Drug Enforcement Administration (DEA), known as the "X-waiver," which effectively hamstrings their capacity to respond to this crisis.[5]

The waiver is particularly rare among emergency physicians, with less than 1% participating in the program.[5] Opioid overdoses and withdrawals are treated on a daily basis by most ED physicians in the United States, and the rates of these visits continue to rise. For instance, opioid-related ED visits increased 30% from 2016 to 2017.[7]

To obtain the waiver, physicians must pay $200 for an 8-hour training course. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), an agency within the US Department of Health and Human Services, only about 5% of all physicians have completed the process, most of whom are family physicians and psychiatrists. After obtaining the X-waiver, physicians can treat only 30 patients in the first year, and then they must reapply to treat more patients.

To ensure compliance with the limit on patient numbers, physicians are subjected to additional oversight by the DEA, and they must keep track of all the patients they are treating with MATs. This requirement was designed for outpatient specialties that monitor and treat patients for extended periods, but these restrictions are impractical and burdensome in the ED because emergency physicians do not manage patients after discharge.

Why Aren't More Patients Receiving MAT After Opioid-Related Overdoses?

Emergency medicine needs to be a larger part of the solution in the opioid epidemic. The legislation needs to better reflect the standards of emergency medicine if broad utilization is desired. In 2000, when the DATA legislation was created, no one could have anticipated the severity of the epidemic to come. The time has come to eliminate counterproductive restrictions and make the legislation more inclusive to all medical specialties.

In a recent study published in Annals of Internal Medicine , of 17,568 patients, only 30% of them were receiving an MAT after an opioid-related overdose.[4] This is shockingly low, considering that the risk for a deadly overdose is markedly higher in individuals who have previously overdosed.[4]

SAMHSA has been outspoken regarding the underutilization of MATs. The current secretary of the Department of Health and Human Services, Alex Azar, told the National Governors Association that not offering MAT for opioid addiction is like "trying to treat an infection without antibiotics."[1]

The X-waiver has also created a significant disparity between counties and states. The Healthcare Cost and Utilization Project statistical report in 2016 showed that more than half the counties in America have no provider with the X-waiver, and the majority of authorized providers actually treat few or no patients.[8] With most US counties having no physicians able to prescribe MATs, more than 30 million people do not have access to buprenorphine treatment.[7]

Opioid-related visits to the ED have increased 99.4% over the past decade.[7] Detox, one of the alternatives an ED physician has to discharging a patient who is in withdrawal, usually provides a short period of MAT while inpatient. However, this often isn't an option, owing to overcrowded facilities and strict requirements for patient participation.

Detox has also been shown to be ineffective in preventing patients from illicit opioid use after discharge. A survey published in the Journal of Substance Abuse Treatment of 164 patients who had inpatient opioid detoxification reported a 27% relapse rate the day they were discharged, 65% within 1 month, and 90% within 1 year.[2] Despite 63% reporting that they wanted to continue MAT, these medications are generally not prescribed upon discharge.

A Strong Argument for Considering Buprenorphine

Starting a patient with opioid abuse disorder on buprenorphine upon discharge has repeatedly shown to be a critical step for patients who seek treatment in the ED. A randomized trial, published in JAMA, of patients discharged from the ED with a prescription for buprenorphine showed a decrease in illicit opioid use from 5.4 days per week to less than 1 day per week compared with patients who received only a single dose of buprenorphine while in the ED.[3]

Initiating buprenorphine therapy not only decreases opioid abuse in the short term, but also has long-term implications for a patient's recovery. Engagement with comprehensive addiction treatments is the most important action a patient can take for long-term success. In 2017, 290 patients who were initiated on buprenorphine from the ED were found to have increased engagement with addiction treatment and reduced illicit opioid use during the 2-month study period.[2,3] Seventy-four percent of patients who were referred to an addiction treatment center and were also initiated on buprenorphine from the ED followed through with formal addiction treatment.[3] These were significantly higher rates compared with patients who only received referral to a treatment center (53%) or only received brief counseling in the ED (47%).

Buprenorphine is more than a substitute for more dangerous opioids. It is a bridge to thorough treatment after an opioid-related ED visit. A near-death overdose is a strong motivator for getting treatment, and without MAT, most patients will go right back to using when withdrawals begin. Restarting illicit drugs puts patients back in the same cycle of using, extinguishing all momentum and motivation toward treatment.

The current administration is allocating billion dollars to fight the opioid crisis, when increasing accessibility comes down to one critical action: lifting the DATA waiver for emergency physicians to prescribe MAT.

The ED does not need to become a glorified Suboxone® clinic; however, emergency physicians need to play a larger role in fighting the opioid epidemic. Physicians have a responsibility to familiarize themselves with the indications, contraindications, side effects, and drug interactions of all medications they prescribe, and MAT is no different. Emergency physicians across the country treat opioid use disorder every day, and training should be part of residency. The current model of optional training, which is required to appropriately treat a condition, has proven ineffective.

The DEA X-waiver has proven to significantly limit the emergency physician's role in fighting the opioid epidemic. MAT education should be integral to residency training in emergency medicine, and the restrictive DEA waiver should not apply to the specialty. The opioid epidemic is costing the country billions of dollars, and people are dying at an unprecedented rate. Changing the restrictions to increase MAT use will decrease the immense strain on healthcare and save thousands of lives.

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