Addiction to prescription painkillers and heroin has grown so deadly that the Obama administration wants to spend more than $1 billion over the next two years fighting it. Nearly all of the money would go to making anti-addiction medications, including buprenorphine, more available.
Yet in the midst of the worst epidemic of unintentional drug overdose in U.S. history - mortality rates are four to fives times as high as in the mid-1970s, according to the Centers for Disease Control and Prevention - it can be harder to get drugs to treat an addiction than it is to get the drugs that feed it.
More than 28,000 Americans died from heroin and painkiller overdoses in 2014, according to the CDC. But fewer than half of the 2.2 million people who need treatment for opioid addiction are receiving it, Health and Human Services Secretary Sylvia Burwell said as President Obama's latest budget was released earlier this year.
Peter Shumlin, D-Vermont, was among the first governors to address the opioid epidemic, devoting his entire State of the State address to the crisis in 2014. Since then, his administration and many of Vermont's private-practice doctors have made treatment more available than it is in most of the country.
Despite that, almost 500 addicts in this state of 626,000 people are on waiting lists to receive medication for opioid dependence. More than half will wait close to a year.
Nationwide, a shortage of doctors willing to prescribe buprenorphine, which reduces drug cravings, and a federal limit on the number of patients each doctor can treat, prevents many who could benefit from the medication from getting it.
Nearly every U.S. physician - there are more than 900,000 of them - can write prescriptions for opioid painkillers such as OxyContin, Percocet and Vicodin by simply signing on to a federal registry. In most states, nurse practitioners and physician assistants can also prescribe opioids.
But to prescribe buprenorphine to people addicted to opioids and heroin, doctors must take an eight-hour course and apply for a special license. So far, fewer than 32,000 doctors have received the license, and most who have one seldomly if ever use it.
Vermont has 248 doctors licensed to prescribe buprenorphine to addicts, according to the Substance Abuse and Mental Health Services Administration, which is part of HHS. Few of them accept new patients who are addicted to opioids.
In the weeks ahead, HHS is expected to propose a change that would probably increase the number of patients a doctor can treat with buprenorphine, possibly with the addition of new licensing requirements.
But many who work in the field of addiction question whether allowing the specially licensed doctors to treat more addicts would do much good. As in Vermont, very few doctors across the country come anywhere close to maxing out on the number of such patients they are allowed to have.
The solution, they say, is for more doctors to prescribe the medication. But that's a long-term solution that involves teaching newly minted doctors about addiction during their residencies and trying to change the hearts and minds of physicians already in private practice, said John Brooklyn, the medical director at the Howard Center, an opioid treatment program in Vermont's Chittenden County. "We're making progress," he said. "But it will take time."
Advocates for greater access to buprenorphine also support a bipartisan bill in Congress - the Recovery Enhancement for Addiction Treatment Act, or TREAT - that would allow nurse practitioners and physician assistants to prescribe it.
Without legislation, HHS has authority only to adjust the patient limit and licensing rules for physicians. Melinda Campopiano, chief medical officer at HHS's Center for Substance Abuse Treatment, agreed that patients with opioid addiction would be better served if more doctors offered addiction screening and treatment.
"What is a concern to me is that more physicians don't feel the responsibility to step up" and get a license to provide buprenorphine, she said.
When approved in 2002, buprenorphine was the first opioid-addiction medication that could be prescribed by doctors. The only alternative at the time was methadone, which had to be dispensed daily at highly regulated clinics.
Although buprenorphine does not produce the euphoric effects of heroin or OxyContin, many drug users purchase it on the street to tide themselves over until they can score the real thing.
Clinical research shows that all three opioid-addiction medicines offer a far greater chance of recovery than treatments that do not involve medication, such as 12-step programs and residential care. Staying in recovery and avoiding relapse for at least a year is more than twice as likely with medications as without them. Medications also lower the risk of a fatal overdose.
Buprenorphine was developed with the idea that family doctors could assess patients with an opioid addiction to make sure the daily oral medication was appropriate and prescribe a monthly supply to be picked up at a drugstore.
Like methadone, buprenorphine is a long-acting opioid that relieves drug cravings and physical withdrawal symptoms with fewer of the side effects of other opioids. It presents a very low risk of overdose unless taken in combination with benzodiazepines such as Valium and Xanax.
The National Institute on Drug Abuse, which funded buprenorphine's development, has urged doctors everywhere to start prescribing it to their patients with opioid addiction. That way, people who respond well would no longer have to travel to a methadone clinic every morning. They could get help the same way people with other diseases do - at their local doctor's office.
So far, that hasn't happened.
In anticipation of buprenorphine's approval by the FDA, a 2000 federal law required doctors to seek a special license from the Drug Enforcement Administration to prescribe it. Without that law, a 1914 federal narcotics law would have precluded doctors from prescribing the drug, and it would have been subject to the same kind of regulation as methadone.
Because buprenorphine is much safer than methadone, Congress wanted to make sure patients didn't have to disrupt their lives by traveling to one of only 1,200 methadone clinics scattered across the country to take the daily medication under strict supervision.
In addition to requiring training, the buprenorphine law limited licensed doctors to 30 patients in the first year and 100 patients in subsequent years. The restriction was meant to discourage what are called pill mills, in which doctors prescribe addiction medications for a cash fee without ensuring that patients are actually using it to recover and not selling it on the street.
Since then, the law has been criticized for contributing to a shortage of prescribers and unfairly singling out addicts and the doctors who treat them. No other medication requires a special license, and no other disease is subject to a patient limit, argued Kelly J. Clark, president-elect of the American Society of Addiction Medicine. She said the rules are symptomatic of the nation's long-standing prejudice against the disease of addiction.
But others argue that the rules are warranted to keep buprenorphine off the streets and to ensure quality treatment.
"Treating opioid addiction with medications has to be more than just medication management," said Mark Parrino, president of the American Association for the Treatment of Opioid Dependence, which represents methadone clinic operators.
If buprenorphine were deregulated, Parrino says there would be no guarantee that patients would get the counseling and regular urine tests that major medical associations agree they should have. Under current rules, the DEA routinely audits physicians to make sure they are keeping records as required and providing adequate treatment.
Here in Burlington, Tom Dalton, director of a publicly funded needle exchange center, agrees that buprenorphine coupled with counseling is ideal. But if that's not available, he said, "we should at least give them a prescription."
When people make the decision to get clean, they should be able to get into treatment immediately. Otherwise, there's a good chance they will disappear, die of an overdose or get arrested, Dalton said. At a minimum, their addiction will escalate, he said. Many who are smoking or snorting opioids start injecting, which spreads diseases such as hepatitis and HIV.
In October, the average wait time to get into the opioid treatment program in Chittenden County was 358 days. But because the waiting list includes pregnant women who by federal law must be treated within 48 hours and intravenous drug users, who must be treated within 14 days, the wait is much longer for everyone else.
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