Commentary on Rhee & Rosenheck (2019): Buprenorphine prescribing for opioid use disorder in medical practice - can office-based out-patient care address the opiate crisis in the United States?

Abstract

In the title of their recent article, Rhee & Rosenheck 1 ask an important question: can the provision of out-patient care in medical settings address the opioid crisis in the United States? As practising physicians in primary care and substance use disorder treatment settings, we agree that expanding treatment of opioid use disorder (OUD) in out-patient settings is critical to stem the crisis. This will require the elimination of key regulatory barriers. Using the National Ambulatory Medical Care Survey (NAMCS), Rhee & Rosenheck 1 reported a nearly threefold increase in out-patient visits involving a diagnosis of OUD from 0.14% of visits in 2006–10 to 0.38% of visits in 2011–15. Across the two time-periods, the proportion of visits involving buprenorphine increased from 56 to 74%. Although some of these visits may represent repeat visits for the same individuals, the overall trends suggest that increasing proportions of patients with OUD were diagnosed and treated. However, the 2011–15 estimates appear low in contrast to results from the 2015 National Survey on Drug Use and Health, that 0.9% of the US adult population met criteria for OUD and nearly 5% reported past-year illicit or non-medical opioid use 2. In addition, more than 47 000 people died of an opioid-related overdose in 2018 3, an almost 66% increase since 2015 4. In this broader context, the increasing trends in visits and treatment for OUD reported by Rhee & Rosenheck 1 are probably insufficient to address demand for evaluation and treatment. Well-established barriers to OUD treatment in US out-patient settings include limited physician training and support, stigma, time constraints and cumbersome regulation 5-7. Regulatory barriers stem from the Drug Addiction Treatment Act (DATA), passed by Congress in 2000. DATA was designed to expand access to OUD treatment settings by removing restrictions on medication treatment of OUD, which had until then been limited to licensed addiction treatment programs. DATA created a process by which physicians could obtain training and receive approval to prescribe buprenorphine in out-patient settings 8. The approval is commonly called the ‘X-waiver’ based on an ‘X’ included in the Drug Enforcement Administration (DEA) registration numbers of approved physicians. Despite the intent of the legislation to balance treatment access with concerns about diversion of controlled substances, by 2017 only a small minority of physicians were waivered to prescribe buprenorphine for OUD, and many counties with high opioid overdose rates lacked any waivered prescribers 9. As health professionals, we should address important barriers to out-patient buprenorphine prescription through educational initiatives, peer support programs and improved clinical pathways 10, whereas policymakers should address critical regulatory barriers to out-patient OUD treatment. For example, the Mainstreaming Addiction Treatment Act (H.R. 2482/S. 2074) was introduced in both the House and Senate in 2019 and would amend the US Controlled Substances Act to end the separate waiver process to prescribe DEA Schedule III–V medications, such as buprenorphine, for the treatment of OUD 11. With this legislation, buprenorphine would be prescribed like other DEA Schedule III medications, such as acetaminophen and codeine combination formulations. As a result, OUD could be treated more like other chronic health conditions. This legislation would considerably expand the capacity of US out-patient settings to address to the opioid crisis. In addition to removing the requirement for the waiver, the Mainstreaming Addiction Treatment Act would authorize a national education campaign to educate providers about the law and encourage them to integrate substance use disorder treatment into their practices. Health professional training programs should supplement this by launching a campaign to prepare the next generation of providers to deliver evidence-based care for OUD 12. The impact of the regulatory change on the US opioid crisis should also be evaluated. As noted by Rhee & Rosenheck, 1 the NAMCS is limited in its ability to characterize OUD treatment patterns. However, existing data systems, such as NAMCS, could be improved, and focused surveillance systems such as the Drug Abuse Warning Network should be instituted or re-instituted 9. With the support of policymakers, these strategies can maximize the impact of out-patient care on the US opioid crisis while allowing us to evaluate and further improve the care we deliver. Outside the affiliations listed, the authors have no financial or other relevant links to companies with an interest in the topic of this article. The content is solely the responsibility of the authors and does not necessarily represent the official views of the University of Colorado, the Rocky Mountain Regional VA Medical Center, Kaiser Permanente Colorado, or Colorado Permanente Medical Group. I.A.B. receives royalties from UpToDate for content on health care for incarcerated adults.