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Sunday, December 4, 2022

America’s opioid crisis is as real as ever — we need policy on safe, effective treatments

The popular TV series “Dopesick,” based on Beth Macy’s nonfiction book, depicts the complexity of assigning blame for the opioid crisis. Several unsuspecting contributors played real-life roles — pharmaceutical companies, federal regulators, and health care professionals. Some mislead people through malicious greed; others try to help but are acting on misinformation.

Legal ramifications are beginning to reflect this blame. Recently, Johnson & Johnson and several Native American tribes reached a tentative $150 million settlement for the company’s role in perpetuating the opioid crisis in their communities.

Blame and justice are certainly important aspects to sort out. Nevertheless, the crisis persists and we must pursue solutions to help the millions of Americans affected by drug use. The numbers are staggering and predicted to increase. According to a recent study, there have been 600,000 opioid overdose deaths in the U.S. and Canada since 1999. The number is predicted to increase to 1.2 million by 2029.

In nursing school, I had two district rotation sites that treated patients specifically with substance use disorder. One was an outpatient program in a wealthy suburb and the other was in an urban location where residents were court-ordered to stay or face legal ramifications. Both patient populations exhibited similar physiological and psychological signs and symptoms that met the diagnosis of substance use disorder.

The stories of life implications were devastating. Damaged established careers, lost university scholarships, fractured relationships. Some patients resorted to selling family heirlooms to pay for opioids, while others sold sex. It was clear to me then that the presence of this condition was indiscriminate and widespread and needed to be part of my primary care practice.

Although the need for intervention is clear, barriers continue to exist for treatment. Substance use disorder is a medical condition, and many patients require medication to treat this disorder. Opioids affect receptors in the brain that block pain and can suppress breathing. This is why it’s important to use medication that acts on these same receptors. Medications such as naloxone block these receptors so the opioids have no effect and can reverse an active overdose.

There have been efforts to increase the accessibility of naloxone to the general public to aid in the overdose response rate. Some schools are considering keeping it on hand and training teachers and staff to decrease their response time to potential overdoses. Supervised drug consumption sites rely on this medication to provide harm reduction to people who use opioids.

Other medications, such as Suboxone, a combination of buprenorphine and naloxone, protect from respiratory suppression but also aid in reducing opioid cravings. While Suboxone has a proven track record as a safe and effective medication, not everyone can prescribe it for substance use disorder because of strict legal limits.

As a family nurse practitioner in Chicago, one of the clinics where I work provides primary care that helps patients manage conditions such as hypertension, depression and substance use disorder. The clinic offers routine care and screenings such as Pap smears, blood draws and medication-assisted therapy for substance use disorder.

While nothing on this list should be an atypical service for primary care, unfortunately, treatment for substance use disorder tends to be sequestered into a separate category and not included with other matters that are routinely managed in the primary care setting. This can contribute to the stigma regarding people with substance use disorder and cause fragmented care.

Physicians, nurse practitioners and physician assistants can prescribe buprenorphine with a Drug Enforcement Administration (DEA) registration, but until recently they were required to have an additional waiver specifically for this medication if they were using it to treat a patient with substance use disorder.

The waiver is not needed for other controlled substances, including opioids such as hydromorphone, oxycodone and morphine. This waiver requires additional education and limits the number of patients a provider can treat based on time. Currently, a provider who has had the waiver for less than a year can treat 100 patients. After a year, the number can increase to 275 patients.

This may sound sufficient, but in a 2020 report published by the U.S. Department of Health and Human Services (HHS), 40 percent of counties in the U.S. did not have any waivered providers. Over 1,000 counties were considered in high need of buprenorphine services and 56 percent did not have adequate capacity.

To address this, HHS passed new guidelines in April 2021 allowing most providers without a waiver to prescribe buprenorphine to 30 patients. This is a step in the right direction, but continued calls persist to remove the barrier of the waiver altogether.

The Senate introduced the Mainstreaming Addiction Treatment Act of 2021 last February. It proposes removing the waiver and is endorsed by those advocating for increased access to treatment. The American College of Medical Toxicology, American Foundation for Suicide Prevention, National Council for Behavioral Health and other organizations have signed letters of support, but the bill has not been passed.  

To be sure, the opioid crisis is complex and multifaceted. There are clear legislation changes that politicians can make to help improve — and even save — the lives of millions of people. It’s time to break down the barriers to make sure that fewer Americans die from opioid overdoses.

Dr. Amanda LaMonica-Weier is a family nurse practitioner and instructor at Rush University, and a Public Voices Fellow of The OpEd Project. 


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