Mr. B undid his arm bandages and revealed two large, gaping wounds where he injected his heroin. He lay back in his hospital bed, looked up at the ceiling and said with a quivering voice, “I can’t inject into my veins anymore because they are all shot. I know I have a problem, Doctor. I’ve been trying to quit, but it’s so hard.”
Mr. B (I’m identifying him only by his initial to protect his privacy) had been using heroin for 20 years after originally being prescribed a common opioid, oxycodone, to treat his pain. He, like many others who had fallen victim to the opioid epidemic, was trying to quit, but methadone hadn’t worked for him. “It made me feel ill,” he said.
I knew of a medication that would treat his addiction and possibly save his life. It has been around for years, is simple to use and is safer than other options. Sadly, I can’t prescribe it. We need to fix this.
The drug’s name is buprenorphine, which was approved by the Food and Drug Administration in 2002. Once absorbed into the blood, buprenorphine targets the same receptor as opiates, partially blocking their effect and limiting the symptoms of withdrawal. Decreased respiratory drive, which can occur with other opioids and can lead to death in overdose, occurs at a very low rate with buprenorphine. As such, it has become the first-line treatment for opioid addiction, but many patients like Mr. B still have trouble getting access to the drug.
Unfortunately, buprenorphine has been limited by regulations that significantly hinder the drug’s widespread acceptance. Any physician who wishes to prescribe buprenorphine has to take an eight-hour online training course. Physicians don’t have to be specially certified to prescribe other medications, and so most physicians aren’t even aware that such barriers exist. Unsurprisingly, 97 percent of physicians are not certified to prescribe buprenorphine.
Arbitrary rules handcuff the few physicians who can prescribe buprenorphine, capping the number of patients that each certified physician can treat. In 2000, federal legislation limited the number of patients undergoing buprenorphine treatment to 30 per physician in the first year, and 100 thereafter. In July, new legislative changes increased the cap to 275 patients. While this represents an improvement, it still limits access to crucial addiction treatment and prevents physicians from devoting their entire practice to opioid treatment. Because of these caps, some stable patients may be forced out of buprenorphine treatment prematurely to make room for a new patient with a more urgent need. Patients like Mr. B, finally able to admit that they have problems with addiction, may have nowhere to turn.
Buprenorphine has been singled out for regulation because it is the first addiction treatment that is safe enough to be prescribed at a regular doctor’s appointment. The United States has always placed strict rules on addiction treatment, partly because past addiction medications such as methadone could lead to overdose or illicit sale on the black market.
But buprenorphine is different. While buprenorphine can be sold illicitly, physicians can switch a patient-turned-seller to methadone, which is administered in specialized clinics to prevent such activity. Additionally, the risk of buprenorphine overdose is one-fourth that of methadone, as a 2009 study of 16,000 people in Australia demonstrated.
Even if I completed all necessary training to comply with federal regulation, I still wouldn’t be able to prescribe the drug. That’s because at the primary-care clinic where I work as a physician-in-training, none of the supervising doctors are certified to prescribe buprenorphine. I have been told that I shouldn’t become certified because “you don’t want to attract those patients to your practice.”
It’s true that many clinicians view patients with chronic pain and opioid addiction as some of the hardest to take care of. We often feel torn between treating real pain and prescribing opioids to feed an addiction that could end in death. This is frustrating because even with the best intentions, we are caught between pain on the one hand and overdose on the other. But this is a false dichotomy. Treating addiction with buprenorphine instead of with opioid painkillers may make these interactions less frustrating, as patients like Mr. B get the care they need.
This can and should be a positive feedback loop. If more doctors become familiar with addiction treatment, stigma will diminish and more physicians will feel comfortable prescribing buprenorphine. But to unleash the potential of well-meaning physicians in combating our nation’s opioid epidemic, the first step must be to remove the barriers to prescribing this medication.
Herein lies our nonsensical system: We physicians have little trouble prescribing opioids, the very drugs that get people addicted. But despite an epidemic where 91 Americans die every day of opioid use, we face arbitrary roadblocks to prescribing addiction treatment such as training sessions and caps on the number of patients who can receive lifesaving medications.
Mr. B was found to have a bacterial infection in his blood, an extremely dangerous condition. Even so, he left the hospital before he could complete a course of antibiotic treatment. He left, in part, because his opioid withdrawal symptoms were too disabling for him to deal with. He probably won’t be counted among those who die of an opioid overdose. But when his infection finally overtakes his body, it will be the lack of access to addiction treatment that truly is to blame.
Jacobs is a resident physician at Brigham and Women’s Hospital in Boston.