Federal prescription drug laws and a lack of trained physicians are hindering access in Black communities to a take-at-home treatment for opioid use disorder, health-care advocates say.
Buprenorphine has emerged as an effective tool in helping people beat substance use disorder. But not many doctors have completed the requisite extra training that would allow them to prescribe it. And a federal cap on the number of patients each health-care provider is allowed to treat with buprenorphine further restricts access to the medication.
That creates a particular challenge for ensuring access to the treatment for patients in Black communities, which face shortages of primary care physicians and die of opioid overdose at a disproportionately high rate.
“This is part of a general problem in our health care system—African Americans have less access to primary care, and that’s where buprenorphine is typically provided,” Emily Feinstein, chief operating officer of the Partnership to End Addiction, said.
Too few doctors are licensed to prescribe buprenorphine, and too few with licenses are located in Black neighborhoods, she said.
Black Americans had the highest increase in synthetic opioid overdose death rate compared to all other populations from 2011-2016, according to a recent Substance Abuse and Mental Health Services Administration report.
And a 2016 study on access to care in Philadelphia found that census tracts with a Black population over 80% were 28 times more likely to have a shortage of primary care providers than tracts with a Black population under 20%.
“We found a bigger variation based on race than on the ability to pay,” Daniel Polsky, one of the authors of that study and a health economist at Johns Hopkins University, said.
“That was a surprising finding, but it looks like providers don’t seem to locate in neighborhoods with a lot of African Americans,” he said.
Access to substance use treatments has become a significant issue during the Covid-19 pandemic. More than 40 states reported increases in opioid-related deaths during 2020, according to an October issue brief from the American Medical Association.
Buprenorphine is an opioid medication that reduces drug cravings and withdrawals and blocks the effects of other opioids. Unlike methadone, a widely used anti-opioid drug that must be dispensed at federally licensed clinics, buprenorphine may be prescribed for take-home use from a doctor’s office.
But doctors who aren’t addiction specialists must complete eight additional hours of training to prescribe it under the Drug Addiction Treatment Act of 2000. Qualifying nurse practitioners and physicians assistants can also prescribe the drug but are required to complete 24 hours of extra training under a 2016 law called the Comprehensive Addiction and Recovery Act.
Just 80,000 health-care providers have undergone that additional training, said Regina LaBelle, program director of the Addiction and Public Policy Initiative at Georgetown Law’s O’Neill Institute for National and Global Health Law. In comparison, more than 1 million providers are licensed to prescribe far more potent controlled substances for treatment of pain and other conditions, she said.
“There’s no question but that this extra training requirement deters practitioners from dispensing buprenorphine,” said Ellen Weber, vice president of health initiatives at the Legal Action Center, a policy group focused on criminal justice and substance use issues.
“It has been demonstrated to reduce deaths from this disease by 50 percent, but federal law imposes education requirements on prescribers of buprenorphine that it doesn’t impose for more dangerous opioid-based medications for other uses,” Weber said.
In addition, federal regulation limits the number of patients with substance use disorder a physician may treat with buprenorphine or other medication-based treatments. The current limit for qualifying physicians is 100 patients for the first year, and 275 thereafter.
That cap, along with the extra training requirements, restricts the number of patients who can get access to the medication, advocates say.
Medication-assisted treatments for substance use disorder are the “gold standard,” according to David Fiellin, director of the Yale Program in Addiction Medicine.
But not all in the substance use field agree: around half of substance use treatment programs eschew the use of medications, relying instead on psychosocial interventions, Fiellin said. Only 10% of people with substance use disorder receive treatment of any kind, and a far lower percentage receive medication-assisted treatment, advocates say.
Buprenorphine is associated with reduced overdose deaths, reduced HIV transmission, and improved social functioning, Fiellin said. It also has a lower risk of abuse than methadone.
That’s why buprenorphine can be prescribed at doctors’ offices rather than in federally licensed and regulated drug treatment clinics, he said.
Being able to access the drug in a doctor’s office allows providers to integrate substance use treatment into broader clinical care, and it lessens the stigma associated with going to a substance use treatment program, LaBelle said.
In addition, patients taking buprenorphine can take the medication home with them, unlike methadone patients who have to show up every day at the clinic for their daily dose for the first 90 days.
That difference removes some significant obstacles for those treated with buprenorphine at the beginning of treatment, LaBelle said.
“If you’re in early recovery you may also be looking for a job, and you may not have transportation or child care,” she said. “The requirement that you show up every day to the methadone-treatment facility really stands in the way of staying in treatment.”
But going the buprenorphine route remains a challenge without an adequate number of providers who can legally prescribe it. Some advocates say the needed training should start in medical school, before physicians start practicing.
“Any physician who expects to prescribe opiates in their practice should graduate from medical school with the skills needed to treat addiction and to prescribe buprenorphine,” Feinstein said.