Policy shift could improve access to buprenorphine for opioid use disorder, but stigma and training still pose significant challenge
Millions of times a day, patients across America get prescriptions for medicines to treat their diabetes, asthma, pain, depression, infections and many more conditions.
Any physician or other licensed provider can prescribe any patient any medication on the market – including drugs that come with serious risks or potential side effects.
If they want to write a prescription for a medicine that’s proven to help people with opioid use disorder – commonly called opioid addiction – those providers need to jump through extra hoops.
The drug is buprenorphine. It’s also an opioid, but it can aid in blocking the action of other opioid drugs – from prescription drugs like oxycodone to heroin -- and help a person overcome the drive to keep using those other substances, without causing a powerful ‘high’ of its own.
A big change
Recently, the federal government removed one of the biggest hurdles to buprenorphine prescribing. Prescribers no longer have to go through hours of carefully scripted special training before they can seek permission to offer it. And those who prescribe it to less than 30 patients no longer have to certify that they can connect patients to additional counseling.
It’s a big policy change, and one that the addiction medicine community had lobbied for.
But experts from the University of Michigan and elsewhere say it’s not the only thing that needs to happen in order to increase the chances that more of the millions of Americans with opioid use disorder can get access to this evidence-based treatment.
“Removing some of the requirements for prescribers who are going to treat a modest number of patients is a step in the direction of reducing barriers, but doesn't overcome the degree to which medical training for addiction is inadequate,” says Amy Bohnert, Ph.D., M.H.S., a health care researcher in the Michigan Medicine Department of Anesthesiology who has studied opioid use disorder care for more than a decade. “In the long run, hopefully this change will combat the perception that buprenorphine is a more dangerous medication than other opioids, or that addiction treatment should only be provided by specialists.”
Even with the changes, providers still need to apply for and receive a special status called an X waiver with the U.S. Drug Enforcement Agency before they can prescribe buprenorphine. That’s separate from the DEA license that most providers receive, which allows them to prescribe other “scheduled” drugs like opioid pain medications. And there are still limits and conditions on how many patients they can prescribe buprenorphine to in a year.
Thuy Nguyen, Ph.D., M.P.A., a health economist in the U-M School of Public Health who studies buprenorphine prescribing by nurse practitioners and physician assistants, agrees.
“Although this is a significant federal effort to expand access to opioid use disorder treatment, it may not be adequate to address important provider and patient barriers such as stigma and lack of care coordination,” she says. “In a recent publication, we found that the effects of the 2016 Comprehensive Addiction and Recovery Act in expanding access to buprenorphine through nurse practitioner prescribing appear relatively small, especially in states with more restrictive scope-of-practice regulations. The findings suggest that there are other important barriers, besides statutory requirements, that must also be addressed to expand treatment access.”
A prescriber shortage
U-M experts say one of the biggest barriers is the chronic shortage of providers who are willing to even start the process of getting up and running with buprenorphine prescribing. And even if they jump through all the hoops, many never actually prescribe a single dose.
Bohnert and addiction psychiatrist Allison Lin, M.D., M.S. co-lead an effort that’s trying to overcome that shortage.
The Michigan Opioid Collaborative offers a range of services to providers across Michigan and beyond who want to offer buprenorphine and other medication-assisted treatment for addiction, and supports them as they offer that care. It’s funded by the Michigan Department of Health and Human Services, Blue Cross Blue Shield of Michigan, the federal Substance Abuse and Mental Health Services Administration and the U-M Department of Psychiatry. Sheba Sethi, M.D., a primary care physician, is the program’s lead physician.
Chris Frank, M.D., Ph.D., is a U-M family physician involved in MOC. He says the demand for the program’s free training has been strong – and expects it to continue even though prescribers won’t be required to have it.
If anything, he says, the lifting of the requirement for specific training frees the team up to adjust their training to suit the providers who want to offer buprenorphine and other medications for other types of substance use disorder in their practices, from treatment programs to primary care providers to emergency department teams.
Keith Kocher, M.D., M.P.H., a U-M emergency medicine physician who leads a statewide quality initiative for emergency department teams called MEDIC, also welcomes the loosening of training requirements. MEDIC, together with the Michigan Opioid Prescribing Engagement Network, has held trainings across the state for several years, and is now planning for more this fall.
“On the surface, this removes a big barrier to prescribing buprenorphine for ED providers – physicians and advanced practice providers,” says Kocher. “However, it will still likely require a nudge for ED providers to apply for the X waiver, and then begin to integrate buprenorphine more intentionally into their practice.”
Gina Dahlem, Ph.D., a nurse practitioner and researcher at the U-M School of Nursing, has also noted that some states do not yet include prescribing of buprenorphine in the scope of practice for nurse practitioners and physician assistants. Allowing such prescribing could also improve access to treatment.
Both Kocher and Frank speak of the stigma associated with providing buprenorphine care.
“The conditions around this treatment have created a sense that there’s something special or difficult about it, but it’s also a stigmatized patient population, though a lot of that is a misperception,” Frank says. “There are patients with substance use disorders who are ‘difficult’ but we treat lots of difficult diseases. And often when we actually treat their substance issues effectively those behaviors often improve or go away completely.
“This is one of those areas of medicine where you really can see people’s lives completely turned around for the better,” he adds. “It’s not an easy quick fix, but we need to see this as a chronic medical condition like diabetes or hypertension.”
Some in the recovery community have hesitated or declined to add buprenorphine to their range of treatment options, focusing mainly on support for abstinence from opioids and situations where drugs are present. Some cite many patients’ need to stay on buprenorphine for months or years to support their recovery.
But the same is true for people with Type 2 diabetes. While a few such patients can go off of medicines that control their blood sugar if they lose a lot of weight, dramatically increase exercise and change their diet, the majority of people can’t achieve a blood sugar target without long-term medication use as well.
Some have also worried about possible diversion of buprenorphine from those who receive prescriptions, thinking they will sell it to others. But those who buy it from a non-prescriber source are often seeking it to treat themselves because they can’t access it in a health care setting, say Bohnert and others.
So, MOC is engaging more with professionals across the recovery community, to try to show how medication assisted treatment can be an important tool.
Even once a provider has gotten started in prescribing buprenorphine, they often find they need help in tailoring the care to certain patients.
That’s why MOC offers same-day help on an on-call basis, and also can offer addiction treatment specialists to take part via telemedicine in a patient’s scheduled visit with their prescriber. The program’s network of behavioral health consultants, located throughout the state, help make the connection between providers – and also help connect patients to local resources.
Starting early – for providers and patients
For Pooja Lagisetty, M.D., M.Sc., another key aspect of increasing the supply of prescribers is to get them while they’re young.
That’s why she’s led an effort over the past three years to train all U-M Medical School students to provide training in medication assisted treatment, so that they graduate with the knowledge they need to do it, and can apply for the X waiver once they are licensed. They may still need mentorship from experienced providers as they enter practice, she says, but they can hit the ground running.
Many U-M medical residents – those doing post-medical-school training at Michigan Medicine’s hospitals and clinics -- can also opt to get buprenorphine prescribing education at U-M.
And soon, a new on-call addiction consult service will be available to any Michigan Medicine provider treating patients in the emergency room and inpatient wards who turn out to have an opioid use disorder and/or another substance issue including with alcohol. This includes those hospitalized after an overdose, but also those in the hospital for any medical condition.
Not only will this allow patients to get started on evidence-based care for their addiction challenge while they are in the hospital for any reason, but it will also allow the trainees involved in their care – including early-career physicians, social workers and pharmacists -- to see addiction medicine being practiced in a real-life setting. The consult service will include professionals from multiple disciplines, including a peer counselor who can speak from the experience of their own addiction, and a social worker to connect patients with resources.
“If we can engage someone during an emergency department visit or inpatient stay, and they can leave the hospital with a prescription and a map for follow-up care, there’s a much higher chance they will stay on it long-term,” says Lagisetty.
The U-M program is patterned after others started in recent years, mostly in major hospitals on the coasts. It’s funded in part by the Michigan Opioid Partnership, through the Community Foundation for Southeast Michigan, which is also funding other hospitals around the state to develop their own approaches to offering more medication-based addiction care.
Lagisetty, a primary care provider herself and member of the faculty in the U-M Division of General Medicine, says institutional support like the kind Michigan Medicine is providing for student and hospital programs is critical to increasing buprenorphine availability.
Including buprenorphine prescribing in the licensing and credentialing process for new physicians and other providers, rather than making them pursue it on their own, could be another step.
“We need to think about why we have historically not done this, including the history of criminalizing people for having substance use disorders rather than treating them medically, especially people of color,” she says. Her own research has shown inequity in the distribution of buprenorphine prescribers.
Lagisetty has also studied the barriers faced by people who take prescription opioids on a long-term basis, for instance for chronic pain. She’s documented the difficulty they may face in finding primary care because of the stigma against taking on an opioid-using patient. That itself can get in the way of potential care to reduce their opioid use through multiple means.
To learn more about the wide range of opioid-related work going on at U-M, visit the Opioid Solutions website.
Many of the faculty mentioned in this story are members of the U-M Institute for Healthcare Policy and Innovation and the U-M Injury Prevention Center, both of which have opioid-related research initiatives as key areas of focus.