While America’s epidemic of opioid use was already a burgeoning health crisis, it has worsened markedly since the onset of the COVID-19 pandemic. Between September 2019 and September 2020, the U.S. Centers for Disease Control and Prevention estimates, deaths caused by opioid overdoses have increased by nearly a third. Dr. Ellen Eaton, of the Outpatient-Based Opioid Treatment Clinic located within University of Alabama 1917 Clinic, discusses the obstacle posed by a two-decade old law as demand for services rises. The good news, she writes, is that a new law can expand access to an urgently needed treatment.
By Ellen Eaton MD, MSPH
During the last year, the number of patients with HIV seeking care for substance use disorders at our clinic has exploded. Patients who were previously in recovery are needing more frequent visits for mental health and addiction support, counseling and social work. Consistently overbooked, we routinely see patients outside of clinic hours to accommodate the demand.
We are not alone in that. Health workers around the country and across the world have faced challenges presented by the COVID-19 pandemic we never could have imagined. At our outpatient opioid treatment clinic within the largest HIV clinic in Alabama, though, one barrier to treatment, and to preventing the spread of other infections is long-standing.
An important aspect of the integrated services we provide is to reduce the harms of substance abuse, including the spread of infections that include HIV and hepatitis C. One of the ways we can do that is through medically assisted treatment with buprenorphine, an FDA-approved medication that helps to reduce opioid craving, illicit opioid use, overdose, and infections transmitted by shared injecting equipment.
A central challenge to providing that treatment, however, has only grown, as the numbers of patients needing treatment grows. That is because law put in place two decades ago requires physicians prescribing buprenorphine to obtain eight hours of special training, while advanced practice providers, which include nurse practitioners and physicians assistants are required to obtain 24 hours of training. In addition, all clinicians are required to submit a special application for the treatment through the Drug Enforcement Agency.
The demonstrated safety and effectiveness of medication assisted treatment with buprenorphine over the two decades since, and the growing impacts of the opioid epidemic, which include the spread of infectious diseases as well as deaths from overdoses, have shown the restrictions to be outdated, and terribly burdensome.
As a result of the restrictions, only about 5% of the nation’s physicians have waivers to prescribe buprenorphine. At our growing clinic, I routinely provide care over my holidays and vacation time because there is simply no one else certified to provide buprenorphine services when I am away.
Fortunately, the White House has responded to growing needs with the release of new guidelines allowing physicians, and select providers, to treat up to 30 patients with buprenorphine without completing training. The guidance, however, still requires the special waiver, or separate registration for the treatment.
The bipartisan Mainstreaming Addiction Treatment (MAT) Act, recently introduced in the House and Senate, however, would change that, eliminating the burdensome requirement for clinicians to obtain a waiver to prescribe buprenorphine for substance use disorder. The new legislation, which carries the benefit of normalizing – destigmatizing – treatment for substance use disorder, offers promise of massively expanding treatment access. When France lifted a similar restriction, the four years that followed saw a nearly 80% drop in opioid overdose deaths.
I hope Congress moves quickly on this legislation. By removing barriers to buprenorphine prescription, the UAB 1917 clinic and other HIV clinics would be able to improve access to treatment that will save lives and reduce HIV transmissions. As HIV, the opioid epidemic, and the COVID-19 pandemic have shown us, we don’t have time to waste.
Ellen Eaton, MD, MSPH is an Assistant Professor of Medicine, Division of Infectious Diseases, at the University of Alabama at Birmingham, and the Director of the 1917 HIV Outpatient Based Opioid Treatment Clinic (OBOT). Her research and clinical care focus on infectious consequences of addiction and mental illness with an emphasis on HIV and bacterial infections. She shares her musings on health, research, and policy @DrEllenEaton
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