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 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:
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A DATA-Waiver, or "X-waiver," registration is no longer required to
treat patients with buprenorphine for opioid use disorder.
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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.
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There are no longer any limits on the number of patients a prescriber
may treat for opioid use disorder with buprenorphine.
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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.
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Clinician peer support is available for physicians or PAs treating
pregnant or parenting patients with substance use disorders. Call
833.937.9326 (Yes-WeCAN).
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The Providers Clinical Support System offers prescribing mentoring
nationwide from a clinical expert through their
online portal.
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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.
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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
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:
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Careful dosing is needed when starting buprenorphine to avoid causing
withdrawal.
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Relief of both craving and pain increase steadily with doses up to 32
mg/day with no "ceiling effect" on analgesia.
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Doses of 2 mg and higher are inexpensive but off-label when used for
chronic pain.
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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.