Tuesday morning. Sarah wakes up at 4 a.m., like every other morning, to go to clinic to get a medicine she cannot function without. But it’s not as easy as that. She has to take her three small children with her because she is a single parent and has no one else to stay at home with them. She does this six days a week. This is her life. This is the reality of methadone clinics, and as a family physician, I worry about the impact this is having on the health and well-being of her family.
The opioid epidemic is increasingly being recognized as one of the largest health care problems facing our nation, and medication-assisted treatment, like methadone, is often at the forefront of discussion. While methadone is a highly effective treatment, more attention needs to be paid to the other FDA approved medication for opioid use disorder, buprenorphine.
As a dual buprenorphine and methadone provider, I have a unique ability to compare these treatment modalities. The evidence and my experience is that buprenorphine is superior across the board in ease of use, withdrawal profile, risk of abuse, dangerous side effects and above all, risk of overdose. As a strong partial agonist of the opioid Mu receptor, buprenorphine has a ceiling effect such that there is almost no risk of overdose, even in combination with other opioids. This is not the case with methadone for opioid addiction, which is reason why it is so highly regulated through specific methadone clinics. While the structure of methadone clinics might benefit some patients, for many patients, like Sarah, it is an almost an insurmountable barrier.
Now if Sarah is lucky and motivated, she might have heard about buprenorphine and desire to give it a try, so she doesn’t have to wake her kids up at 4 a.m. every day. But then comes her next challenge. She has to find an “X-waivered” provider, or someone licensed to prescribe buprenorphine. As of 2015, only 3 percent of primary care physicians in the U.S. have such prescribing privileges. The majority of rural counties in the U.S. have no X-waivered providers. In order to receive an X-waiver, physicians have to complete eight hours of additional training, and mid-level providers have to complete an additional 24 hours.
My question is why do these regulations exist at all? As a physician, I can graduate my internship and prescribe as much Norco, Vicodin, Percocet, Oxycontin, Morphine, Fentanyl and even methadone that I deem necessary to treat pain with absolutely no additional training. These medications carry extremely high risks for side effects, misuse, and overdose leading to death. Yet when my patients get addicted to these medications, I cannot immediately offer them the much safer alternative opioid, buprenorphine, to treat their addiction. Furthermore, even if I do go through the training and legal process to get my X-waiver, I am still restricted in the number of patients for whom I can treat with buprenorphine; 30 in the first year and 100 in the year after that. Meticulous bookkeeping is required to keep count of these patients should we ever get audited by the DEA, increasing administrative burden.
The Drug Addiction Treatment Act of 2000 was a huge step forward in increasing access to buprenorphine in the outpatient setting by allowing physicians with an X-waiver to prescribe buprenorphine. Now that we have nearly two decades of clinical experience to show that buprenorphine MAT can be done safely and effectively in the outpatient setting, I argue that we don’t need to require providers to obtain an X-waiver anymore.
The opioid epidemic has been declared a national health emergency, and this extra regulation for providers is simply another barrier to addressing the problem. I urge my medical colleagues to pressure their legislators to create common sense laws that will allow buprenorphine, in conjunction with standard addiction behavior therapy, to be prescribed in all outpatient clinics without all the cumbersome regulations that currently deter many physicians.
Christina Kinnevey is a family physician.
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