'Get Out of the Way DEA,' Physicians Bid to Treat Addiction

Ingrid Hein

December 05, 2019

Emergency physicians in the United States are calling again for changes to legislation so that they can more easily prescribe buprenorphine to patients with opioid addictions.

Currently, physicians must take an 8-hour course before they can prescribe the medication for opioid withdrawal and then wait up to 90 days for the US Drug Enforcement Administration (DEA) to issue a special "X waiver."

During the first year of the waiver, physicians can treat a limited number of patients and must submit a report for each treatment prescribed. Each patient can only receive one day's worth of buprenorphine to manage withdrawal symptoms, and must return to the hospital each day for subsequent doses.

"You have folks who are not capable of managing their lives very well and you decrease their resources and expect them to do better," said Vidor Friedman, MD, from AdventHealth in Orlando, Florida, who is past president of the American College of Emergency Physicians (ACEP).

"It doesn't make any sense," he told Medscape Medical News.

"Buprenorphine is the most important medication in our arsenal for treating opioid use disorder, which is currently the most lethal disease in the US for Americans between the ages of 20 and 50," Friedman recently wrote — in his capacity as ACEP president — in a letter to Brenda Destro, PhD, deputy assistant secretary for planning and evaluation at the US Department of Health and Human Services.

Some clinicians are not willing to pursue this DEA license or even engage in treatment of patients with opioid use disorder.

But stigma associated with the X waiver means that "some clinicians are not willing to pursue this DEA license or even engage in treatment of patients with opioid use disorder," Friedman explained in the letter. "This waiver requirement creates a misperception that buprenorphine is more dangerous than other things we prescribe, and that's just not true."

"Every single cancer drug out there can kill you, has significantly more side effects than buprenorphine, and you don't need additional education to prescribe," he pointed out. Buprenorphine and methadone have been "singled out."

Buprenorphine is a common drug of abuse and is sometimes used in place of heroin. It can be used recreationally by injection or in the nose for the high it produces. In the United States, it is a Schedule III controlled substance.

Adverse effects associated with buprenorphine can include respiratory depression, sleepiness, adrenal insufficiency, QT prolongation, low blood pressure, and allergic reactions.

People who come to the emergency department with opioid use disorder are scared, Friedman pointed out, "but we can't treat them like we do any other disease process."

"We treat their withdrawal as best we can" and offer a referral on discharge, but "the loop is not always closed."

The letter calls for Congress to pass legislation that eliminates the X waiver requirement and suggests that emergency physicians be able to dispense a 3-day supply of buprenorphine "or administer a dose that will last for at least 3 days," such as an intramuscular injection.

In addition, ACEP is asking that the preauthorization required by insurers be removed. Only about 25% of patients land in the hospital during office hours, so getting authorization for the other 75% is impossible.

Legislation needs to change, Friedman said. "Buprenorphine is not an opioid to treat pain, it is a treatment for opioid addiction."

"You have people clambering up and down, saying 'do something about opioid use disorder.' We, the medical community, are responding. Help us do our jobs; get out of the way," he said. "We need reasonable solutions to this problem."

A treatment pathway program for buprenorphine that eliminates barriers to treatment for patients with opioid use disorder has been instituted at Tampa General Hospital in Florida.

Treatment Pathway

"We have a handful of physicians with an X waiver. They are on call 24/7 if a patient needs a dose of buprenorphine," said Heather Henderson, a PhD candidate at the University of South Florida and director of social medicine strategies at Tampa General.

Patients are asked if they want to take part in the program, which ensures that they get a "warm handoff" to an "actual person" at a treatment center the hospital partners with.

"If there is a transportation issue, we arrange it for them. If they come in when the treatment center is not open and we feel they can't be successful if they leave, we keep them overnight to get them stable," Henderson explained.

To date, the success rate has been 50% for the 138 patients who have been enrolled in the program, she reported. And although there have been successes and failures, in all cases, she has seen positive reactions from patients.

"I remember one woman who came in who was in severe withdrawal," she said. The woman was in her early twenties and had three children. She wanted to stop using so she could get back to her children.

"When we told her we had a treatment pathway, she broke down and cried she was so happy," said Henderson. Unfortunately, this patient "wasn't able to complete the structural component of the pathway at the center." A few months ago, she was back in the hospital for an overdose. She didn't make it.

Although the failures are heartbreaking, the success stories are inspiring, such as the couple who presented with severe withdrawal symptoms but completed the program.

They were really motivated to recover, she said. "About halfway through the treatment process, he broke his neck and pelvis in a car accident, but told the physician, 'don't give me pain medication, I'm in recovery'."

"They now have a child together and the mother is working to become a certified peer-recovery specialist," Henderson told Medscape Medical News.

"Before the creation of the program, there was no protocol for buprenorphine," she said. "If we hadn't built the treatment pathway in our emergency room, would we have seen that success?" She doesn't think so.

And physicians are feeling more empowered since the program was put in place. They "love having something they can do for the patient. They thank us for improving their quality of life at work. That's been wonderful," she said.

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