An Effective Treatment for Opioid Addiction Exists. Why Isn’t It Used More? (partly regulations)

A drug called buprenorphine may be the best tool doctors have to fight the fentanyl crisis. Why hasn’t it been more widely adopted?

By Moises Velasquez-Manoff. Excerpts:

"The missteps of the medical establishment didn’t stop with the first wave. The second wave of the opioid epidemic began when that establishment, realizing what it had unleashed, made medical-grade opioids much harder to obtain. Though this might have seemed like a reasonable and corrective step to take, the problem, some experts now argue, was that patients on opioids had developed a kind of disease: opioid-use disorder, more commonly referred to as opioid addiction. This would have been the opportune moment to deploy medicines, like buprenorphine, to set users on a path to recovery. Instead, the medical profession “abandoned millions of people,” Herring says. “We let millions of people just fall.” Physicians who might have wanted to prescribe buprenorphine faced significant hurdles, like training requirements and limits on the number of patients who could be treated."

"But even as awareness of buprenorphine has spread, the extent of its use is nowhere near what experts think is needed. “Every county should have at least one place where someone could walk in and that same day get buprenorphine regardless of their ability to pay for it,” Kolodny says. But a 2022 study found that only about half of the nation’s top-ranked hospitals said they provided buprenorphine in their emergency department. Hundreds of counties still lack any M.A.T. providers at all, according to a recent report from the inspector general’s office at the Department of Health and Human Services. And where those providers do exist, they often won’t accept Medicaid or Medicare patients. (Many providers won’t accept any insurance at all, Kolodny says.)"

"Experts also point to the onerous regulations that long governed the use of buprenorphine. It was approved to treat opioid addiction in 2000 — the earliest version available consisted of a tablet dissolved under the tongue — but limits on how many patients doctors could treat with the drug (no more than 30), coupled with training requirements before they could prescribe it to patients, caused many doctors to eschew it altogether. These regulations have been lifted piecemeal over the years. The X waiver, a certification that doctors needed before they could prescribe buprenorphine, was eliminated only in 2023. Yet even as the drug has become freer in a regulatory sense, and therefore easier to give to patients, the number of prescriptions written for buprenorphine has not meaningfully increased, according to C.D.C. data."

"As I asked around, however, it was easy to find people who disagreed with anything that resembled a mandate. Representative Paul Tonko of New York, though he lamented to me the slow adoption of buprenorphine, nonetheless suggested that a directive pushing hospitals and doctors to provide the opioid risked sparking a backlash. A much sounder approach, in his view, would be to remove the remaining barriers to the medicine’s full rollout. The D.E.A.’s monitoring of the drug has a chilling effect, he argued, making even pharmacies reluctant to stock too much of it, because they don’t want to attract the agency’s attention. To reduce this “fear factor,” Tonko recently was a sponsor of a bill that would temporarily exempt buprenorphine from the D.E.A.’s oversight."