healthmedicinet

The recent and alarming rise in overdose deaths across the country has exposed the need for more doctors to treat addiction and for expanded prescribing capacity for the ones that already do. In January of last year, a Huffington Post investigation found that without access to MAT, people with opioid addiction were struggling in traditional, abstinence-only treatment centers, which tend to shun the use of medications like buprenorphine (commonly sold as Suboxone) and methadone. A follow-up story showed how rural areas in particular are failing to meet demand for those medications, with patients having to travel hundreds of miles to find a doctor willing to treat them.

“The acceptance of medication-assisted treatment — there has been an evolution,” Burwell said. “We’re getting to a place where it’s much more accepted.” But she cautioned there are still too many affected families and treatment facilities that aren’t informed about MAT. “I think we have more work to do to make sure that people know that this is an evidence-based tool.”

The patient limits were originally set out of a fear that buprenorphine, a semi-synthetic opioid that can produce a high if used incorrectly, would be diverted to the black market. But studies have shown that the vast majority of those buying the medication illegally are doing so to self-treat their addiction. In other words, the lack of legal access has actually helped spur the black market.

When Burwell visited Congress before her confirmation in 2014, the patient limits came up in conversations with lawmakers. “The buprenorphine cap was something that was brought to my attention in a number of different ways,” she said. “Sen. [Carl] Levin, who is no longer a senator, handed me a number of pieces of paper and articles about this issue — I still remember, I came into the meeting to talk about my confirmation and this was the issue he wanted to focus on,” she recalled.

Last September, Burwell announced that reforms were coming before a conference of the country’s treatment system administrators and doctors meeting in Northern Virginia. When she broke the news, the room erupted with applause.

Officials within HHS then began meeting with everyone across the federal government who had a stake in the opioid crisis, from the Drug Enforcement Administration to the White House’s Office of National Drug Control Policy, to figure out just where to establish the new patient limits. The DEA offered no resistance to expanding access to buprenorphine, Burwell said. 

That response suggests a thawing of the relationship between the two departments. “In general, the history has not always been a smooth and easy one between HHS and DEA, but you couldn’t have asked for better partners than them this time,” said Richard Frank, HHS’s assistant secretary for planning and evaluation. “I think people have figured out that we’re not going to arrest our way out of this problem, and I think there’s been sort of a change in leadership and attitude from bottom to top.”

The question that officials discussed wasn’t whether to expand the patient limit, but by how much. “Nobody knows, like, the magic number here, right?” Frank told HuffPost. “We were sort of balancing two principles: We wanted to do something that we thought would meaningfully expand access, but we wanted to move cautiously because there are risks of diversion.”

Under the proposed rule, a certified doctor who wants to go to 200 patients must also provide those patients with access to behavioral health services and have a plan in place to prevent diversion of the medication to the black market. Frank said HHS would be evaluating the impact of increased patient capacity as well.

If the 200-patient limit proves not to be high enough to meet demand, he said, HHS can propose further adjustments.

The American Society of Addiction Medicine, for example, had wanted to phase in a 500-patient cap. The Senate health committee recently passed an amendment that recommended a similar increase.

The amendment also called for nurse practitioners and physician assistants to be able to prescribe buprenorphine. Frank said HHS doesn’t have the authority to include such medical personnel in its proposed rule. But it hopes to do a large-scale pilot program with nurse practitioners and physician assistants.