Medications for Opioid Use Disorder

Passed by Congress in December of 2022, the Consolidated Appropriations Act for 2023 included key provisions from the Mainstreaming Addiction Treatment Act (H.R. 1384/S. 445), federal legislation supported by the WSMA and addiction treatment professionals intended to address America's worsening overdose crisis. Those provisions remove federal barriers to medications for opioid use disorder and increase access to life-saving treatment that prevents overdoses and supports recovery.

The WSMA is grateful for the leadership and advocacy of Lucinda Grande, MD, Olympia addiction medicine physician, who, as a delegate to the WSMA House of Delegates, authored Resolution C-15 on behalf of the Thurston-Mason County Medical Society, which called on the WSMA to support federal efforts to eliminate the buprenorphine waiver requirement. The resolution was passed by the 2019 WSMA House of Delegates and provided the policy underpinning for WSMA's advocacy on the issue.

MAT Act Snapshot: What It Means for Physicians and PAs

According to the DEA, DEA-licensed prescribers should be aware of the following:

• A DATA-Waiver, or "X-waiver," registration is no longer required to treat patients with buprenorphine for opioid use disorder.
• Going forward, all prescriptions for buprenorphine only require a standard DEA registration number. The previously used DATA-Waiver registration numbers are no longer needed for any prescription.
• There are no longer any limits on the number of patients a prescriber may treat for opioid use disorder with buprenorphine.
• The act does not impact existing state laws or regulations that may be applicable.

Resources for Initiating Buprenorphine

Don't know where to start? These resources can help.

WSMA addiction medicine training meeting new DEA Requirement

The Consolidated Appropriations Act of 2023 enacted a new one-time, eight-hour training requirement for all DEA-registered practitioners except veterinarians on the treatment and management of patients with opioid use disorder or other substance use disorders. The WSMA, in partnership with with the Washington Society of Addiction Medicine, Women and Addiction Group, and CHOICES Education Group, offers free on-demand addiction medicine training to meet this new requirement. Access the virtual CME on WSMA’s Compassionate Addiction Medicine webpage. This activity is approved for AMA PRA Category 1 Credit^TM.

Other resources

• The Substance Abuse and Mental Health Services Administration offers a downloadable buprenorphine quick start guide and pocket guide.
• The UW Psychiatry Consultation Line provides clinical advice to physicians, physician assistants, and other eligible health professionals regarding adult patients with mental health or substance use disorders. You can contact them at 877.WA.PSYCH (877.927.7924) or pclwa@uw.edu.
• Clinician peer support is available for physicians or PAs treating pregnant or parenting patients with substance use disorders. Call 833.937.9326 (Yes-WeCAN).
• The Providers Clinical Support System offers prescribing mentoring nationwide from a clinical expert through their online portal.
• Opioid Response Network offers educational and training assistance at no cost to clinical administrators. Visit their website, where you can submit a request for training. Or contact orn@aaap.org or 401.270.5900.
• The Washington Society of Addiction Medicine holds virtual monthly CMEs on various addiction-related topics. You can also join a listserv to get help from addiction medicine doctors. Contact them at wsamweb@gmail.com.

More Information

• DEA announcement
• SAMHSA Removal of DATA Waiver Requirement
• Health Care Authority medications for opioid use disorder

Buprenorphine: A Versatile New Tool

By Lucinda Grande, MD

It literally took an Act of Congress. The tangle of red-tape known as the buprenorphine "X-waiver," required previously to prescribe buprenorphine for opioid use disorder, was finally cleared away by the Mainstreaming Addiction Treatment (MAT) Act in December 2022. As DEA-licensed prescribers, we all now have a powerful and versatile addition to our toolkits.

Buprenorphine has two tightly intertwined roles. It wipes out opioid craving and withdrawal. It also is a safe and effective opioid treatment for chronic pain, laboratory-designed and initially used as an analgesic, a fact that should interest every one of us. With the MAT Act, the artificial boundary between these two roles is now gone.

Buprenorphine reduces opioid overdose deaths by 50% or more. The heartbreaking failure of this country to wield such a powerful tool in the midst of the deadly and accelerating fentanyl overdose crisis conferred urgency to the MAT Act. Such heartbreak drove dozens of organizations in Washington state and hundreds nationally to urge Congressional action. As noted by Eliza Hutchinson, MD, my partner in building this state's broad coalition, "In this moment of extremely divisive politics, it is inspiring to see folks of all professional and political stripes … working together in the face of such a crisis."

The MAT Act is long overdue. Back in 2006, the maddening overlap between chronic pain and addiction drew the attention of Roger Rosenblatt, MD, a family medicine research pioneer and a mentor to both Eliza and me. Roger's attention became riveted on the vast uncontrolled prescribing of opioid pain medicines. He discovered the devastating effects of those medicines on rural communities. He saw first year medical students become jaded and bitter, disillusioned by the intense pressure from an avalanche of needy patients demanding refills of their pain pills.

Roger then discovered buprenorphine. He was fascinated by its precision as a tool to fix this tough set of problems, due to its unique pharmacology. Buprenorphine provides pain relief but not euphoria. It relieves craving and withdrawal without causing respiratory depression, so overdose is nearly impossible. Roger developed an aggressive program to get physicians X-waivered, so they could treat patients whose opioid use disorder had become prominent. Of note, buprenorphine was legal to prescribe for chronic pain even before the MAT Act, but the confusing regulations deterred prescribing.

Then in 2020, a blue-ribbon panel of national pain specialists threw their support behind buprenorphine for chronic pain in a review in Pain Medicine. A key message was that "buprenorphine be considered before some Schedule II, III, or IV opioids in patients with a favorable risk-benefit profile."

New prescribers can learn helpful tips from an experienced colleague or from training materials. For example:

1. Careful dosing is needed when starting buprenorphine to avoid causing withdrawal.
2. Relief of both craving and pain increase steadily with doses up to 32 mg/day with no "ceiling effect" on analgesia.
3. Doses of 2 mg and higher are inexpensive but off-label when used for chronic pain.
4. Contrary to popular belief, buprenorphine and traditional opioids can be prescribed and used together for chronic or acute pain, with an individually variable analgesic "sweet spot."

The MAT Act is a common-sense solution to prevent opioid overdoses, increase treatment access and reduce stigma. It is now up to us to use our new versatile tool to help patients struggling with addiction, chronic pain, or both.