More than 2 million Americans struggle with opioid use disorder (OUD), a chronic relapsing medical condition, but access to medication-assisted treatment—the most effective therapy—remains limited. Buprenorphine, one of three drugs approved by the Food and Drug Administration to treat OUD, helps alleviate painful symptoms associated with the disorder. But few clinicians prescribe the drug.
Dr. Rebecca Haffajee, assistant professor of health management and policy at the University of Michigan School of Public Health, and Dr. Eric Ketcham, an emergency physician and addiction specialist with Presbyterian Healthcare System in New Mexico, are both experts in addiction medicine. They recently offered their perspectives on why buprenorphine treatment is not more readily available and what policies could help expand access to this lifesaving therapy. Their responses have been edited for clarity and length.
Q: What factors prevent buprenorphine from being more widely prescribed to treat OUD?
Haffajee: Ironically, federal legislation intended to expand access to treatment for OUD—the Drug Addiction Treatment Act of 2000—has discouraged buprenorphine prescribing because it requires health care providers to get additional training and receive permission from the Drug Enforcement Administration (DEA), known as the X-waiver, before they can prescribe the drug in outpatient settings. And these requirements exacerbate other barriers.
Stigma, for example, from both providers and patients, is a major concern fueled in part by the X-waiver. Many practitioners perceive patients with OUD as a more challenging population to treat. They may view them as untrustworthy or likely to divert the medication to others. And patients—who may struggle to find a provider even willing to treat them—are often fearful of being labeled as having an addiction, given the negative connotations often associated with such a label.
In my research, we’ve observed physicians, nurse practitioners, and physician assistants express concerns about the lack of institutional and peer support for prescribing buprenorphine. These providers do not want to be the only ones in their practices offering this medication. They want peer and mentor support, both in managing the patient load and in getting input from colleagues when treating difficult cases.
Ketcham: Without question, the X-waiver—which allows physicians to prescribe buprenorphine for OUD only after completing eight hours of training and obtaining a special license from the DEA—is the biggest hindrance to treatment. For doctors who maybe don’t want to treat patients with OUD, it’s easy to use the waiver requirement as a way out. But even motivated prescribers face limitations.
In my trainings, providers can apply for a DEA license immediately, but they still wait up to 90 days for the agency to process the application before they can prescribe. How many patients could we have helped in that time? In addition, a DEA license only allows prescribers in a primary care setting to treat up to 30 patients in the first year. When you consider the prevalence of this disease, this cap keeps people from accessing lifesaving care.
The X-waiver was born from the stigma associated with addiction and our collective failure to recognize this condition as a disease. Prescribers are not required to undergo training or obtain certifications for any other drug—including other opioids or benzodiazepines, the drugs most frequently involved in overdoses. For too long, addiction medicine has not been a part of standard medical education and training, and patients are suffering as a result.
Q: If buprenorphine were deregulated by removing the X-waiver, would providers face other barriers to prescribing it?
Haffajee: Issues associated with the training will persist even if prescribing buprenorphine is deregulated. As it stands now, many clinicians that I’ve surveyed report that the X-waiver training isn’t appropriately targeted—both that course material is too general and focused on basic controlled substances or that it doesn’t include information about the newer drug formulations available.
For example, providers seem to know little about Probuphine, a new, implantable form of buprenorphine that could help address diversion concerns. Nobody is prescribing it, in large part because no one knows anything about it. Even without the waiver requirement, we need to think carefully about how to effectively train providers—especially those working in primary care and emergency medicine—in addiction medicine, whether in medical school or through continuing medical education.
Providers also say that reimbursement is an issue. Many state Medicaid programs cover some form of medication-assisted treatment. But certain reimbursement practices, such as prior authorization or lifetime limits—where Medicaid will only pay for a set amount of treatment before the insurance benefit runs out—hinder access.
Ketcham: Stigma will remain an issue too. Many providers are just uncomfortable with buprenorphine and the idea of prescribing it to treat OUD. So we have to help providers understand that addiction is a disease in need of treatment rather than a moral failing. But we also have to work with health insurers, both private payers and Medicare and Medicaid.
It’s a fairly laborious process to prescribe buprenorphine because many insurers require prior authorization—that is, providers must obtain approval in advance to make sure the insurer will cover the costs associated with treatment. For emergency medicine physicians like myself, this can be a serious problem. We have a perfect opportunity to reach patients where they are—in our emergency departments, when they have experienced an overdose, when they are in withdrawal, and when they are often desperately seeking help. We can initiate OUD treatment with buprenorphine. But the need for prior authorization can stop me dead in my tracks. Just try to complete a prior authorization request in the middle of the night; it’s almost impossible.
Q: Aside from deregulation, what policies can help increase buprenorphine prescribing?
Haffajee: We can consider several policies. First, we should pursue educational campaigns for providers and patients that encourage buprenorphine prescribing and treatment. We’ve also got to focus on augmenting the provider workforce. How can we incentivize physicians to pursue careers in primary care medicine—often the only type of care available in rural areas—and be willing to treat addiction? Congress is trying. Lawmakers passed legislation last year that offered loan forgiveness to providers willing to practice in areas hardest hit by the overdose crisis.
We can also invest more in telehealth and telemedicine so providers in urban areas can treat patients in more rural parts of the country. And we’ve got to increase peer and mentor support for providers who are taking on patients with addiction. The Providers Clinical Support System, an initiative of the Substance Abuse and Mental Health Services Administration, is a great peer mentorship program that connects providers interested in treating patients with OUD, but more people need to use it.
We should also invest in more robust addiction medicine training in both medical schools and continuing medical education. And we need to better enforce federal law requiring parity for mental and behavioral health services. The Mental Health Parity and Addiction Equity Act is meant to ensure health insurers offer equally robust medical and behavioral health benefits. Unfortunately, some insurers have found ways to skirt the rules, which has limited access to treatment.
Ketcham: From a federal perspective, we need more funding for treatment. And we’ve got to make sure insurance supports, rather than hinders, access to treatment. When insurance doesn’t cover certain treatments or requires prior authorization for others, access will inevitably be limited.
We also have to keep fighting the mischaracterization of addiction and help more providers understand that OUD is a medical condition that can be managed like other chronic diseases. Understand, there’s no code for admitting someone to the hospital with a substance use disorder so I can initiate treatment with medication. A patient must be otherwise medically ill with a condition necessitating hospitalization, such as experiencing complications of severe withdrawal or suffering from a serious infection due to intravenous drug use. Psychiatric hospital admission can be even more restrictive, with more limited access.
If I were allowed to admit patients with substance use disorder alone—much like I could for patients experiencing cardiovascular issues—I would be able to harness all of the hospital’s manpower, including case management services, to help keep people safe, develop a discharge plan, and hopefully put them on a path to recovery.
Ultimately, we can’t lose sight of the fact that there is a tremendous return on investment for getting people into treatment. We would never stand for these mortality rates, especially among young people, if we were talking about heart disease. We can reduce morbidity, we can reduce mortality, and we can reduce health care costs associated with OUD—but the first step is making buprenorphine readily available to those in need.