My patient was a young man who wanted to be placed back on buprenorphine. He had started using again. He often missed appointments, did not pick up phone calls. So when I saw him in the room, I masked my surprise. “What makes you want to start today?” I asked. “I live with my grandma,” he said. He could not keep leaving the house for heroin.
Of the many issues that undergird health care delivery in the age of COVID-19, medications for addiction treatment (MAT) is one of the most compelling alarms for broader structural changes during and after this pandemic. I work in a clinic that serves as a medical home for people who have interfaced with the juvenile justice system. As jails and group homes try to lessen their numbers, the number of patients who need to connect with care for the first time only increases — as does the demand to start or continue MAT.
In my pre-pandemic haze, I saw the control of buprenorphine scripts to be a kind of boon to ensuring longitudinal care. There was an incentive for patients to come to their appointments, during which time they revealed their career goals, the desire to start families, fears of dying. MAT was a bridge towards a trusting relationship with a provider.
Now, the feeling of a boon has given way to the feeling of unfettered bureaucracy. Even as opioid overdose is the leading cause of accidental death, buprenorphine remains a tightly regulated drug. Providers need to complete an 8-hour training course in order to obtain a prescription waiver, and there are a limited number of patients providers can treat — 30 in the first year and a maximum of 275.
With COVID-19, we have both the unique opportunity and need to deregulate buprenorphine prescriptions. The Substance Abuse and Mental Health Services Administration (SAHMSA) recently updated guidelines for buprenorphine prescriptions. There are new provisions for telephonic initiation of buprenorphine and scripts up to 28 days for stable patients. Unfortunately, this does not circumvent the major issue: redeployed providers will not be able to fill scripts. With just 7% of providers nationally able to even prescribe buprenorphine, this is a particularly vulnerable window for care. We must instead take the current crisis as an opportunity to reform and strengthen MAT access.
First, developing mechanisms for rapid access is critical: not all pharmacies have the capacity to accept electronic scripts for controlled substances. This is an easy means to ensure that patients do not have to leave their homes for prescription pick-ups. Statewide databases for prescription monitoring can make it easy to safely refill buprenorphine, especially when patients are least likely to leave the state. We should also enable telephonic refills. Pharmacists can be trained in accepting security questions from providers prior to filling scripts. Another potential solution is to have providers give their patients a pin number to refill prescriptions should the provider be redeployed or ill. A corollary effect may be improving patient self-efficacy, especially for young people who are more likely to be in transient housing situations where adult oversight is limited.
Second, we need to expand training for buprenorphine initiation and management. With a dearth of addiction medicine in medical education, we limit trainees from becoming interested and, therefore, involved in times of crisis. Expansions in the number of patients are contingent upon oversight from those already with a waiver — a bottleneck effect on rapid training. Given the number of furloughed mid-level practitioners, we could use this time to build capacity for MAT management. SAHMSA has issued some flexibility to permit certified mid-levels to prescribe MAT without direct physician supervision. The need for MAT access will continue to rise, compounded by the reorganization of treatment facilities and detention centers. Our clinic is already finding itself overwhelmed with an uptick of referrals. We are left telling families and patients to wait: we don’t have enough providers, we need to space out visits. And every week, we forego the opportunity to intervene sooner and keep our highest patients at home.
Third, we need to liberalize the length of prescriptions. Prior to COVID-19, buprenorphine prescriptions were dispensed for 14 days. Under new guidance from SAHSMA, scripts can be extended to 28 days — a thoughtful, but incomplete solution. Instead, we need to consider patients on a case by case basis and allow patients to have a refill. Barriers to care, such as housing instability, unemployment, and transportation mean patients are at increased danger of not being able to connect with a provider. While there is a risk of hoarding or diversion, the cost is minimal compared to having a patient return to the streets for heroin.
Structural inequities undergird so much of opioid use disorder: They create, enforce, and exacerbate it. If we were blind to it before, we are now acutely aware that our personal choices are both created and limited by our biases. We don’t need to wait for a pandemic to end before we re-envision both our choices and our beliefs.
Megana Dwarakanath is a pediatric resident.
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