Twenty-two Department of Health directors co-signed a letter to U.S. Department of Health and Human Services Secretary Alex Azar last week urging the federal government to expand access to medications used to treat people struggling with opioid addiction. State directors described how federal law is burdensome for providers who wish to prescribe Buprenorphine, an FDA-approved medication used to treat opioid addiction, and requested federal action to eliminate barriers to prescribing it.
That same morning, I rounded the hospital wards meeting with patients who are actively struggling with opioid addiction. More than a handful of my patients were admitted for intravenous drug use related infections of their skin, bones or heart valves. Each patient described the challenges they faced from opioid addiction. One described starting heroin as a teen. Another described becoming dependent on prescription opioids after suffering a traumatic injury and later using heroin to alleviate pain and withdrawal after the medication dose administered for years was suddenly reduced. One was on Buprenorphine-Naloxone (Suboxone) and another on Methadone. A few of them described difficulties in finding a doctor to prescribe Buprenorphine. By the afternoon, I too wanted to sign my name urging HHS to de-regulate Buprenorphine.
We are in the midst of an opioid epidemic. A recent article suggests that from 2016 to 2025, approximately 700,000 Americans will die from opioid overdose. Treating addiction is key to combatting the crisis. Buprenorphine, itself an opioid, does just that. Heroin and drugs like oxycodone act on opioid receptors in a similar way to how a key fits a lock, the combination creating the sensation of euphoria. Buprenorphine acts as a misshapen key that only partially fits the lock; it creates little to no euphoria and minimizes cravings. Buprenorphine is proven to reduce relapse, physical and mental harm of opioid addiction, and the risk of dying from overdose. On a macro level, it is an essential medication for combatting the opioid epidemic. On an individual level, it can allow a person to manage an addiction, sustain meaningful work and relationships, avoid incarceration; it can mean life over death.
Floridians experience a higher rate of overdose deaths compared to the national average. Numerous groups in Florida are helping to address this issue. The University of Miami IDEA Exchange program has helped to reduce the spread of HIV and Hepatitis C by providing free, sterile needles to those who use intravenous drugs. Legislative efforts are under way to expand needle exchange programs across the state. Naloxone, the opioid overdose reversal medication that can be administered by bystanders, is available without a written prescription. At the hospital I work at, the emergency department established a pipeline program that identifies patients with opioid addiction and plugs them into a treatment program that same day.
Despite these efforts, people with opioid addiction struggle to obtain Buprenorphine. Doctors can only prescribe Buprenorphine if they have an X-waiver, a special authorization through the Drug Enforcement Administration. Obtaining one is time-consuming and creates an unneeded obstacle that indirectly harms patients. One study reported that only 20 percent of Americans with opioid addiction received treatment within the past year. How can they when less than 5 percent of physicians have an X-waiver? And how can they when six in 10 rural counties in the United States do not have a physician eligible to prescribe Buprenorphine?
Some argue that deregulation may lead to overprescribing and misuse of the medication. But we know that the most commonly cited reason people use Buprenorphine without a prescription is to prevent opioid withdrawal. People are buying black market Buprenorphine not to get high but to treat their opioid addiction!
Prescribing Buprenorphine should be deregulated so that any doctor can prescribe it. Addiction is a disease and just as we should not expect primary care physicians to undergo a special waiver training process to prescribe blood pressure medications, we should not expect them do to the same to treat opioid addiction. There would be national outrage if people with diabetes were unable to find a doctor legally authorized to prescribe insulin and yet, that is the reality for people with an addiction to opioids.
The Florida Department of Health should co-sign the letter urging HHS to deregulate Buprenorphine. Florida local and national lawmakers should follow the recommendation of our nation’s top addiction experts to eliminate the X-waiver. #XtheXWaiver has recently trended on social media.
My arsenal of medications to alleviate human suffering include treatments for high blood pressure, diabetes, and infections to name a few. Like many physicians, I want access to the tools to treat opioid addiction. On behalf of the people I serve, let’s #XtheXWaiver.
Dr. Bryant Shuey is an internal medicine resident at the University of South Florida Morsani College of Medicine.