One Big Roadblock to Opioid Addiction Treatment

The crisis of opioid abuse continues in the United States. However, a new study finds there still aren't enough doctors authorized to prescribe the leading drug treatment for opioid addiction.

This shortfall occurs even though the number of physicians approved for the drug, called buprenorphine, has risen dramatically over the past decade, researchers say.

Right now, fewer than 1 in every 10 doctors have received the U.S. federal waiver required to prescribe buprenorphine. The drug is more effective and easier to access than the other leading treatment, methadone, noted study author Ryan McBain, a policy researcher at the RAND Corp.

Still, the number of authorized buprenorphine prescribers increased fourfold between 2007 and 2017, up to more than 56,000, McBain said.

"It's a huge increase, and it's exciting to see that," McBain said. "On the other hand, there are over 600,000 primary care providers in the United States, which means that more than 90% of providers still are not waivered to provide treatment. That's the downside."

Meanwhile, the number of opioid overdose deaths increased from about 16,500 in 2007 to about 46,000 in 2017, McBain said.

"The size of the problem is also increasing dramatically over the same period," McBain said. "We're trying to play catch-up with the scope and the scale of the epidemic."

Doctors have to apply for a waiver from the U.S. Substance Abuse and Mental Health Services Administration to be able to prescribe buprenorphine, a requirement that's been in effect since 2002, according to the agency.

Buprenorphine has increasingly become the preferred method of treating opioid use disorder in the United States, McBain said.

"It connects with people's opioid receptors in their brains, but it doesn't have the same effect as a full agonist like if you were using heroin or you were at a methadone clinic," McBain said.

Buprenorphine also has a "ceiling effect," he added.

"You can take more and more buprenorphine, but the effect of it levels off even if you take more of a dosage," McBain said. "That's not true of other things, like methadone."

Using federal data, McBain and his colleagues found that the number of physicians who've gotten the waiver still remains small relative to the growth of the opioid epidemic.

However, there's one good piece of news in the data.

"We found a fairly happy story, which is that providers are more likely to have one of these waivers in communities with the highest rates of opioid overdose deaths," McBain said. "The hardest-hit areas of the opioid epidemic saw a fivefold increase in waivered providers over that period, versus counties with the least need."

There are a number of different reasons why doctors aren't getting this waiver, experts said.

Getting the waiver requires taking an eight-hour class that counts toward a doctor's continuing education, so "the barrier to being able to prescribe buprenorphine is not massive," McBain said.

The waiver does cap the number of patients to whom a physician can prescribe buprenorphine. In 2017, about 7 out of 10 doctors with a waiver were allowed to treat only 30 patients.

However, doctors very often don't treat as many opioid addicts as they are allowed under their waiver, and some don't use the waiver at all after they've gotten it, said Lindsey Vuolo, director of health law and policy at the Center on Addiction.

Vuolo believes that "stigma and discrimination against buprenorphine create barriers to care."

"Providers may be unwilling to prescribe and patients unwilling to take buprenorphine because of the incorrect belief that because buprenorphine is an opioid, it 'substitutes one addiction for another,'" said Vuolo, who wasn't involved with the study.

McBain said that doctors also might be concerned that treating opioid addicts will take too much time away from the rest of their practice, and might even drive their current patients away.

"If we suddenly start treating opioid use disorder at my primary care facility, then what happens if my normal clinic gets overwhelmed and my regular clients freak out and they leave?" McBain said.

Finally, physicians could be concerned that they might be biting off more than they can chew if they take on addiction treatment, McBain said.

"There's also generally a feeling that, well, I could get this waiver but I'm not an addiction specialist and I don't know that I'm really going to have the skill set to help people who have such severe needs," McBain said.

Pilot programs have been established to help connect doctors on the front lines of the epidemic with addiction experts at high-level medical centers, McBain said. Physicians are able to consult remotely with experts regarding specific patients, and get advice for the best care.

Regulators also are starting to relax the rules surrounding who can receive a waiver. In 2017, nurse practitioners and physician assistants were added to the list of health care professionals who can apply to prescribe buprenorphine, McBain said.

Increasing addiction training among health care workers also could help, as well as improving insurance reimbursement rates for treating substance use disorder, Vuolo said.

McBain added that it might be time to consider doing away with the waiver requirement altogether.

McBain noted that after France deregulated buprenorphine prescribing, "over the three years subsequent to that deregulation, the number of opioid OD deaths declined by 79%, a huge decrease just by making the barriers for providers lower."

The new study was published January in the Annals of Internal Medicine.

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