Health Care/Joan Retsinas

The Government: Erasing the X in Prescribing Buprenorphine

Remember the chestnut from philosophy classes: what happens if a tree falls in a forest, and nobody hears it? Does it make a sound? Similarly, what happens when Uncle Sam removes a restriction from drug prescribing, and few people heed it? Does it matter?

We are testing that chestnut, as the roll-out of the government’s change of heart commences.

Briefly, physicians, along with addiction specialists, had long recognized the utility of buprenorphine in treating addicts. The drug reduced cravings, reduced the criminal activity linked to drug abuse, and reduced deaths. Analysts declared the drug cost-effective. In this time of staggering opioid statistics, buprenorphine marked a win from Big Pharma! But only 27% of patients who might have benefited took the drug.

The reason lay buried in the bureaucratic regulations of the United States Drug Enforcement Agency. Physicians could prescribe buprenorphine to treat pain, but not to treat addiction. To do that, a physician needed to undergo special training, and register for an “X-waiver,” to be added to his/her registration number. Without the X-waiver, the physician could not prescribe the drug, regardless of the need of a patient, regardless of the efficacy of the drug. The DEA, moreover, placed a limit on the number of patients an “addiction clinician” could treat. For physicians and patients, the X-waiver marked a cruel roadblock to treatment.

The DEA feared that opening that road would lead to more prescriptions being written, as well as more being sold on a black market. Consequently, while physicians specializing in addiction qualified, the vast majority of physicians did not: the Officer of the Inspector General found that only 5% of physicians qualified, generally not in the counties with the highest need.

Dec. 29, 2022, marked an extraordinary move: Uncle Sam removed the roadblock. When President Biden signed the Consolidated Appropriations Act of 2023, he put into motion the Mainstreaming Addiction Treatment Act. That act X-ed the need for an X-waiver.

With the X-removed, a host of physicians, including nurse practitioners, could prescribe buprenorphine; and a host of patients who need help would no longer need to seek out a treatment-specialist. Nor would patients need to risk the stigma of seeking out those “addiction” specialists. A patient could go to the primary care physician who already treats him/her.

Now that we eliminated the need for an X to prescribe buprenorphine, one optimistic estimate is that the United States might see at least 30,000 fewer opioid deaths. (When France relaxed regulations for prescribing buprenorphine, statisticians saw a 79% reduction in opioid deaths over three years.)

But to date the word has not spread beyond the substance abuse agencies. After the press releases, the nation’s mainstream physicians, particularly those who serve rural and minority patients — the people who have less access to addiction clinics — have not seized this chance to help their patients.

In a “First Opinion,” for State News (Feb. 14, 2023), Beth Linas and Benjamin Linas, an epidemiologist and a physician, write: “The X-waiver for buprenorphine prescribing is gone. It’s time to spread the word.”

It now behooves everybody concerned with the tragedy of opioid addiction to speak to their physicians, to speak to the families of people struggling with addiction, to speak to those patients themselves — in short, to announce that patients who need help can get it more readily.

Liberals and conservatives often lament Uncle Sam as the Big-Regulator, erecting barriers that do more harm than good. At last Uncle Sam took down one barrier.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email joan.retsinas@gmail.com.

From The Progressive Populist, April 1, 2023

Populist.com