By Rachel Crumpler
Every morning when Drug Enforcement Administration Administrator Anne Milgram goes into the office in Arlington, Virginia, she walks by walls covered in photos of people of all genders, ages and races.
She passes by portraits of more than 4,800 faces — all of people who died as a result of the synthetic opioid fentanyl.
One of the photos is of Tyler, his face frozen in time, forever 24 years old. Milgram talked about Tyler at a White House event last week on removing barriers to addiction treatment.
She recounted how he struggled for six years with substance use disorder and relapsed the day before he died. Tyler and his mom had spent that day unsuccessfully seeking treatment. Then he overdosed.
Nearly 107,000 people died of drug overdoses nationwide in 2021, according to the latest data available from the Centers for Disease Control and Prevention. In the same year, close to 4,000 North Carolinians died, and preliminary data for 2022 indicates that number likely climbed even further.
The Substance Abuse and Mental Health Services Administration’s 2021 national survey on drug use and health found that 16.5 percent of the population — or 46.3 million people aged 12 or older — met the criteria for having a substance use disorder in the past year. Twenty-four million individuals were classified as having a drug use disorder.
There’s long been a problem connecting people with opioid use disorder to treatment. But now federal officials have removed a big barrier to connecting patients to treatment — a federal limitation on doctors’ prescribing practices. The change increases the number of providers eligible to prescribe buprenorphine by nearly 14 times. This will likely result in increased access to care for North Carolinians struggling with substance use, eventually.
Opening access
Medication-assisted treatment is considered best practice for treatment of people with opioid use disorder and has been proven clinically effective — far more effective than abstinence-based treatment alone. Buprenorphine is one of three medications approved by the U.S. Food and Drug Administration to treat opioid use disorder. The medication has been shown to suppress withdrawal symptoms, reduce drug cravings and decrease the risk of overdose death.
Until recently, one barrier to prescribing buprenorphine had been that clinicians had to obtain a special DEA license called an X-waiver. And it came with prescribing limitations.
In practice, medical professionals say, that has made it more difficult for them to offer prescriptions to treat opioid use disorder than it is to prescribe opioids for pain management.
Only about one in 10 eligible medical professionals completed the training to prescribe buprenorphine, leading to a shortage of addiction treatment providers in some areas. The gaps in coverage disproportionately hit rural residents of color.
But the Mainstreaming Addiction Treatment Act, signed into law by President Joe Biden in December, eliminated the X-waiver requirement.
Milgram said the policy change will drastically boost the nation’s number of eligible buprenorphine prescribers from 130,000 to 1.8 million, making treatment more accessible.
“That is in every state in the country, rural, suburban and urban,” Milgram said. “It does change the game.”
About the X-waiver
Some clinicians viewed the X-waiver as burdensome. For physicians, the training was eight hours. For advanced practice nurses and physician assistants, it was 24 hours. The training could be completed online, but for already overworked medical professionals strapped for time, training wasn’t often a priority.
Regulations also restricted the number of patients with opioid use disorder that health care providers could treat.
Need for more prescribers
The removal of the X-waiver comes at a pivotal time, said Rahul Gupta, director of the White House Office of National Drug Control Policy. Overdose deaths are continuing to rise, and fewer than 1 out of 10 Americans with substance use disorders get the care they need.
“To my colleagues in the medical field, now is the time to join in treating patients with addiction,” Gupta said. “I’m a primary care physician, and when I began first seeing patients with addiction, I thought treating them was the job of addiction doctors. But then I realized that my patients needed me to step up.”
A recent CDC study found that nearly one-third of counties nationwide lack a buprenorphine provider. NC Health News’ own analysis last summer found 14 of the state’s 100 counties — all rural — had no buprenorphine prescriber.
Moreover, of the state’s around 1,600 authorized buprenorphine prescribers, 75 percent of them were concentrated in the state’s 22 urban and suburban counties, which leaves significant coverage gaps.
With a shortage of prescribers and some of the available ones located far away, medication-assisted treatment remains inaccessible for some despite its proven success.
Time off work, the cost of gas and even access to transportation can pose insurmountable barriers to getting treatment.
David Sanders, a physician assistant who has prescribed buprenorphine for more than five years, works in primary care in Stokes County and has seen the challenges firsthand. Previously, he was the only buprenorphine prescriber in the county, and he sees most of his buprenorphine patients at a substance use disorder clinic in High Point — at least 45 minutes away.
For some patients that Sanders referred to the High Point clinic, the routine was too burdensome and they could not keep up with treatment.
“They might go once or twice, but then they can’t keep up,” he said. “They don’t have a ride, or they lost their license because of a DUI. They can’t do it. Those patients are the ones that fall through the cracks and can’t get the care they need.”
Willing to treat?
While it’s now easier to start prescribing buprenorphine, that doesn’t mean the pool of buprenorphine prescribers will expand immediately.
Clinicians have to first be willing to treat patients with opioid use disorder. They also need to have the time, capacity and knowledge to do so.
Opioid epidemic in North Carolina
- In 2021, an average of 11 North Carolinians died each day from drug overdose.
- From 2000 to 2021, more than 32,000 people lost their lives to drug overdose in the state.
Data from the NC Opioid and Substance Use Action Plan Data Dashboard
“Most of the time, I see clinicians get in certain habits and prescribe certain medicines and don’t branch out to the unfamiliar,” Sanders said. “So this, especially in the short term, is still going to be unfamiliar. It actually won’t surprise me if there’s still an access problem.”
For years, Blake Fagan, a family physician in Asheville, encountered patients with opioid use disorder. He didn’t have his X-waiver, so he told them he couldn’t help and that all he could do was refer them elsewhere in the community. He said few patients took the next step — afraid to cold call a clinic for an appointment, fearful of judgment.
In 2013, a patient he had been seeing for years landed in the emergency room and died from an overdose.
“That changed my life,” he said. “I started trying to read about what could I have done to help this person and realized that she had all the signs of opioid use disorder — and I just wasn’t looking for it.”
The experience pushed him to get his X-waiver so he could treat patients with opioid use disorder. Now Fagan directs MAHEC’s office-based opioid treatment services. He said he doesn’t want other providers to have to experience a patient’s death to get them to act.
In the years since, he’s spearheaded education and training for medical providers and residents across the state about prescribing buprenorphine. To date, Fagan said MAHEC has helped train more than 1,000 providers in North Carolina so that they can feel comfortable screening for and prescribing medication for opioid use disorder.
Fagan also said that North Carolina has prioritized medication-assisted treatment training for health care professionals, taking a multi-tier approach of teaching medical students, residents and current providers. All five medical schools in North Carolina now have integrated opioid use disorder training into their standard curriculum, so graduates enter the medical setting prepared to address the needs of patients with opioid use disorder.
Fagan welcomes the elimination of the X-waiver, which he said will open the door for many providers to start prescribing.
“Now every doctor, nurse practitioner, physician assistant and certified nurse midwife can write this medicine just like they write high blood pressure medicines or diabetes medicine,” he said. “It opens up access.”
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I need to see proof of sucess in treatment with MAT.