SMajor challenges remain before most U.S. clinicians feel comfortable treating patients with buprenorphine, according to a new study.
While recent federal government moves to deregulate buprenorphine led to an increase in prescribers, this did not lead to a significant increase in overall prescribing volume. Many health care providers still find it difficult to prescribe buprenorphine, or simply have little interest in using the medication, the study found.
The research, published Friday in the JAMA Health Forum, highlights two major challenges: allowing U.S. health care providers to provide addiction drugs and then convincing them to actually use the drugs to treat patients.
“The number of people getting the amended waiver increased, but the number of people getting buprenorphine prescriptions really didn’t change,” said Chris Jones, the study’s lead author and a veteran federal addiction policy officer who currently serves as director of the Center for Disease Control and Prevention’s injury prevention division. “This survey allowed us to dig into: Okay, so you made the move to get the amended waiver. What are the other challenges you face with why you don’t prescribe?”
The new research follows several government actions that have made it significantly easier to provide buprenorphine, the only drug available outside of a specialty clinic that treats opioid addiction by helping to reduce cravings and withdrawal symptoms.
However, as of late 2020, prescribers had to undergo special training to obtain what is called an “X-waiver” or “DATA-waiver”, a special permit just to prescribe buprenorphine. The license required eight hours of additional training for physicians and 24 hours for nurse specialists and physician assistants.
The Trump administration effectively eliminated the requirement during its final days in power, allowing healthcare providers to treat up to 30 patients with buprenorphine without additional training. Upon taking office, the Biden administration temporarily suspended the ordinance, but in April 2021 introduced a nearly identical policy.
More recently, Congress abolished the education requirement outright, meaning healthcare providers are effectively free to treat buprenorphine as they treat other drugs. However, prescribers certified by the Drug Enforcement Administration must still complete training to maintain their license.
However, the relaxed restrictions have not completely solved the problem. Despite the increased number of buprenorphine suppliers, overall prescription volumes have not increased significantly according to recent research.
The new survey helps explain why. Physicians reported a laundry list of other obstacles preventing them from prescribing buprenorphine, ranging from concerns about the DEA’s reach, insurance approval processes, lack of institutional support, concerns about buprenorphine abuse, and concerns about treating patients with opioid use disorder. In addition, a large number of physician assistant prescribers and nurse specialists reported being unable to find a supervising physician to oversee their practice, which is still required in several states.
“The findings suggest that as implementation of legislation removing the DATA exemption begins, addressing these barriers may be essential to increasing access to buprenorphine,” wrote the paper’s authors, who include top officials from the Substance Abuse and Mental Health Services Administration and other government agencies.
Public health experts and the Biden administration have long identified increasing access to addiction medication as a key pillar of the country’s opioid crisis response. Currently, only two drugs are approved for the treatment of opioid addiction: methadone and buprenorphine. However, methadone is only available at specialty clinics, leaving buprenorphine as the sole weapon in many US providers’ anti-addiction arsenal.
Even as the federal government lifts restrictions around buprenorphine, the drug has become more difficult to use. In particular, the prevalence of fentanyl has made doctors rush to help patients avoid a condition known as accelerated withdrawal—essentially withdrawal symptoms that stem from buprenorphine’s relative weakness in the face of fentanyl’s immense potency.
But buprenorphine remains an essential tool for treating opioid use disorders, Jones stressed. While the elimination of the X exemption did not immediately lead to a substantial increase in the number of prescribers or the total volume of prescriptions, he added, such an increase is possible if the medical community, and the country more broadly, can continue to change the culture around addiction treatment.
“We also need to educate and engage with patients with opioid use disorder so that healthcare providers feel more comfortable,” said Jones, “and raise awareness about the very real benefits, the life-saving benefits, of buprenorphine and opioid use disorder drugs. Not just among clinicians, but also among patients.”
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