The pandemic’s epidemic: opioid use disorder and subpar suboxone access   

The COVID-19 pandemic has devastated America’s health, taking more than 500 thousand American lives, upending the economy, and perpetuating racial health disparities. It also has worsened the country’s ongoing opioid use disorder (OUD) epidemic. In fact, in the twelve-month period ending June 2020, 83 thousand Americans died of a drug overdose, the highest ever recorded in a one-year period and 21 percent higher than the previous year. This dramatic increase in overdose deaths is mostly attributable to the synthetic opioid fentanyl.

The U.S. government has minimized its approach to the OUD epidemic, much as it did the initial wave of COVID-19. Although the US government has appropriately emphasized expanding access to naloxone, an effective medication for treating opioid overdose, it continues to restrict access to the medicine that treats OUD itself, buprenorphine.

First discovered in 1966, buprenorphine is a strong partial opioid agonist, meaning that even though it tightly binds to the same receptors on the brain as other opioids, its molecular structure makes it dramatically less likely to cause life-threatening respiratory depression or overdose compared to other full opioid agonists. Thirty-six years after its discovery, the FDA first approved Suboxone (buprenorphine-naloxone) as a daily medicine for the treatment of OUD in 2002. Studies show that patients who use buprenorphine for OUD are more likely to remain in treatment and are less likely to engage in behaviors that can lead to serious infections like endocarditis, hepatitis C and HIV and are less likely to die of overdose.

Unlike methadone, an opioid agonist which may be used to treat OUD only in specialty addiction treatment settings, buprenorphine may be prescribed by any waivered prescriber.  This not only increases access to buprenorphine but also reduces stigma by allowing treatment of OUD by primary care providers just as any other chronic medical condition such as diabetes or hypertension.

Despite these clear individual and public health benefits, U.S. federal law as outlined in 21 U.S.C. § 823(g)(2) of the Controlled Substances Act (CSA) restricts health care providers from treating patients with OUD, requiring that physicians take 8 hours of additional training, and requiring physician assistants (PAs), nurse practitioners (NPs),  and other qualifying mid-level health care providers take 24 hours of additional training to be permitted to prescribe buprenorphine for OUD. In contrast, no additional training requirements exist for health care providers to prescribe all other opioids.

Limiting the ability to prescribe buprenorphine has implications for medical trainees.  Provision of buprenorphine in current practice is highly associated with buprenorphine training during residency, but the current regulatory and training burdens limit the adoption of buprenorphine prescribing among physician trainees. Just one-third of family medicine, internal medicine, and psychiatry residencies encourage obtaining a waiver to prescribe buprenorphine.

The result of this slow expansion of buprenorphine prescribing access has been devastating for access to care for safe, effective, and affordable care for OUD. Currently, there are 96 thousand health care providers authorized to prescribe buprenorphine for the more than two million Americans with OUD. Further, it has limited patient access to buprenorphine providers in rural areas where they’re needed most, exacerbating rural health inequities. In 2015, overdose deaths in rural areas surpassed overdoses in urban areas. Yet in 2018, nearly 30 percent of rural Americans lived in a county without a buprenorphine prescriber, and more than half of all rural counties were completely without a buprenorphine prescriber at all.

Recognizing the need for expanding provider access to buprenorphine prescribing abilities, the U.S. Department of Health and Human Services (HHS) in January of this year announced it would exempt DEA registered “physicians from certain certification requirements needed to prescribe buprenorphine for opioid use disorder (OUD) treatment.” Despite general enthusiasm for this change, President Biden’s drug policy office reversed course and stated that “the (HHS) announcement was made prematurely.” This hesitance is understandable, given that HHS may not have had sufficient authority to make change entirely through regulatory changes when restrictions surrounding buprenorphine prescribing are codified through law.

However, even though the historic American Rescue Plan Act of 2021 passed this month provides funding for the distribution of opioid reversal agents (e.g., naloxone) and counseling and education services for Americans with OUD, Congress and the executive branch missed an opportunity to change policy surrounding buprenorphine prescribing.

OUD is an epidemic that existed before COVID-19, and although it was exacerbated by the pandemic, OUD will linger long after the last American contracts the COVID-19 virus. Legislation dedicated to eliminating barriers to buprenorphine is long overdue. Lives depend on it.

Jonathan Staloff and Claire Simon are family medicine residents.    

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