A recent study conducted by the U.S. Department of Health and Human Services Office of Inspector General finds that a potentially effective treatment for opioid use disorder is not widely available in the communities most affected by the problem. The use of buprenorphine, a drug used to manage the symptoms of opioid withdrawal, has been hampered by regulations and controversy. As a result, more than half of the US counties with the highest rates of opioid addiction don’t have any access to the treatment at all.
Buprenorphine is a partial opioid agonist, meaning that it binds to the same opioid receptors in the body that commonly abused opioids such as heroin do. Because of the similarity, buprenorphine calms the withdrawal symptoms experienced by patients attempting to recover from the abuse of other opioids. It also reduces cravings for abused drugs.
Buprenorphine, however, doesn’t produce the same feelings of euphoria that other opioids do, so it’s less likely that patients will abuse it. Withdrawal from buprenorphine itself is also relatively mild compared to other opioids.
A significant advantage of buprenorphine as a treatment for opioid use disorder is that it can be prescribed and administered in a doctor’s office. Other treatments such as methadone are only available in drug treatment centers. The hope is that patients will be more likely to seek treatment if they can do so through their primary care providers, rather than having to enter into a drug treatment program.
Despite the treatment’s promise, access to buprenorphine remains limited. In order to be allowed to prescribe buprenorphine for opioid use disorder, doctors must complete an 8-hour online training course and obtain a waiver from the federal government. The Inspector General’s report found that there are no waivered doctors in 40% of all counties nationwide. Even worse, 56% of the counties that the Inspector General has identified as most in need of treatment services had no waivered providers.
The report also points out that the problem is deeper than it may seem at first glance. Even in counties that are served by waivered providers, those providers aren’t prescribing buprenorphine to the allowed number of patients.
Controversy and Disagreements
If buprenorphine works, why are doctors reluctant to prescribe it? The reasons are complex, and they involve both the business of being a healthcare provider and broader concerns about the nature of the treatment itself.
Many doctors are wary of the workload associated with treating opioid use disorder. Especially in communities that are heavily impacted by opioid abuse, being the only doctor authorized to prescribe buprenorphine could translate into an unwanted influx of patients. A survey published in the Journal of Substance Abuse Treatment found that 36% of waivered doctors said they didn’t have time to treat more patients, and 55% said that they had no interest in prescribing more buprenorphine. Among doctors who did not have a waiver, 30% said they were worried that becoming waivered would bring too many requests for buprenorphine to their practices.
A quarter of the doctors in the survey also said they were concerned that the buprenorphine they prescribed would end up in the illegal market on the street. Although there is an illicit market for buprenorphine, proponents of the treatment argue that illegal users are using the drug not to get high, but to self-treat their own withdrawal because they have no other way to get access to buprenorphine.
The situation highlights another obstacle in the way of buprenorphine treatment. The most popular approach to opioid abuse treatment follows an abstinence-only model, in which only complete abstinence from all substances is considered acceptable. Using one drug, buprenorphine, to treat addiction to another drug is completely contradictory to this model.
Proponents of buprenorphine argue that the effectiveness of abstinence-only treatment has not been scientifically proven and that medication-based treatments like buprenorphine appear to be much more effective. The disagreement likely underlies much of the reluctance to promote the widespread use of buprenorphine.
The report from the Inspector General came down unambiguously on the side of the buprenorphine boosters. The report recommended that the Substance Abuse and Mental Health Services Administration use its resources to encourage doctors in vulnerable communities to obtain waivers and to encourage waivers in those communities doctors to step up their use of the treatment.
US Department of Health and Human Services Office of Inspector General, Geographic Disparities Affect Access to Buprenorphine Services for Opioid Use Disorder
Medpage Today, Why Do So Few Docs Have Buprenorphine Waivers?
Journal of Substance Abuse Treament, Why aren’t physicians prescribing more buprenorphine?
The National Alliance of Advocates for Buprenorphine Treatment, What exactly is Buprenorphine?