The tragedy of the opioid epidemic is inescapable. According to the latest provisional numbers from the Centers for Disease Control and Prevention (CDC), opioids were involved in more than 47,000 overdose deaths in 2018--that’s more than 5 people every hour. American life expectancy is declining for the first time in more than 50 years, attributed to the dramatic increase in drug overdose deaths. This tragedy is recounted in headlines and obituaries and statistics, but the dashed dreams and potential of those lost is immeasurable.
There is no panacea for this epidemic; complex social problems require multifaceted solutions. Yet, in the midst of this crisis, we are making some progress.
A Promising Increase in the Midst of the Crisis?
In 2018, 1.9 billion e-prescriptions crossed our network, and of those, more than 115 million were for controlled substances, according to our 2018 National Progress Report. More specifically, the number of buprenorphine e-prescriptions that crossed our network increased more than 88% from 2017 to 2018, largely driven by the increasing number of clinicians using E-Prescribing for Controlled Substances (EPCS). (This upward trend in buprenorphine prescriptions is supported by other evidence: an Urban Institute analysis of Medicaid-covered prescriptions for opioid use disorder from 2013 to 2018 found that the number of buprenorphine prescriptions increased 3.7-fold from 1.77 million to 6.47 million.) Furthermore, buprenorphine use relative to e-prescribed opioids increased by 24% (from 5.8 to 7.4 per 100 opioid e-prescriptions) according to our data analysis, which examined the period of 2017 to 2018. What does this mean? This increased use suggests that clinicians are using EPCS to help treat opioid dependence and addiction, as well as securely prescribe opioids to patients in legitimate need of pain relief.
Approved for clinical use by the Food and Drug Administration nearly two decades ago, buprenorphine is used in medication-assisted treatment (MAT) to help people reduce or quit their use of opioids. The drug helps stop cravings and blocks withdrawal symptoms common in people dependent on opioids.
So does this increase in buprenorphine e-prescriptions offer a glimmer of hope? Here’s what this looks like in the real world:
Dr. James Anderson runs a lauded medication-assisted treatment program (MAT) for opioid addiction in central New York. The Bassett Healthcare Network program treats patients with opioid use disorder in a primary care setting, a novel approach that eases access to, and destigmatizes, treatment.
Practitioners in the network have been encouraged to obtain DEA-issued waivers that allow them to prescribe buprenorphine to patients as part of an office visit. When Bassett’s MAT program began in 2016, two primary care clinicians held such a waiver; the number has since increased to 60. To date, the program has served and treated more than 700 patients.
Meeting Patients Where They Are
Many of the program’s patients had been prescribed opioids for pain. The next part of this story is a sadly familiar one in communities across the country: when those prescriptions became harder to come by, black market heroin slid in to fill that void in his community, Anderson explained.
“There are really only three treatments that have demonstrated clinical efficacy in helping people get off and stay off of heroin. If you're not doing one of them, I would argue that you're really not offering best-evidence treatments. These are methadone, naltrexone or buprenorphine,” said Anderson. “Naltrexone is given in an injectable form and stays active in a patient’s system for about a month. There are times and places where that treatment may be a good and reasonable option for a patient. Methadone has efficacy, as well, but our community is rural. From any point in our region, our patients are looking at about an hour drive, one way to get to the clinic. And these clinics typically ask folks to come in daily.”
“Instead, we’re meeting patients where they are physically, geographically,” he said. “E-prescribing buprenorphine works for our patients.”
When a patient starts the MAT program, the clinician begins a process called “induction.” Simply put, the clinician helps the patient move out of withdrawal with increasing doses of buprenorphine until withdrawal symptoms dissipate. The patient can undergo induction at the primary care office or at home, following the instructions of his or her clinician. In the next stage of treatment, which occurs the very same week as the induction, the patient is e-prescribed buprenorphine and comes in for follow up visits. During those same-week visits, the clinician monitors the patient’s progress and determines if the patient is taking the medication as prescribed.
As more time passes between a patient’s recovery and active addiction, patients may only come in for office visits every 2 to 3 months.
There are added benefits to treating addiction in primary care, said Anderson. A clinician is also able to screen the patient for medical problems that co-occur with addiction, such as Hepatitis C and HIV, provide birth control for women struggling with addiction, as well as identify opportunities for behavioral care if the patient is open to it.
Anderson noted that he has seen a number of patients turn their lives around after starting Basset’s MAT. He talked about a man in his mid-forties, who has struggled with trauma since childhood.
“He had been buried alive in his thirties and had many broken bones,” said Anderson. “When he came into treatment, he was taking well over 100 milligrams a day of full agonist opioids.”
Full agonist opioids bind tightly to the opioid receptors to produce maximal effect, according to The Pharmacy Times. Examples of full agonists include codeine, fentanyl, heroin, hydrocodone, methadone, morphine, and oxycodone.
The CDC guideline on opioid prescribing for chronic pain urges prescribers to avoid doses of more than 90 milligrams a day.
Anderson said that the man has been on buprenorphine for a couple of years now.
“Now there certainly have been some hiccups,” he said. “He still has some pain and anxiety. He still is prescribed, on occasion, some full-agonist opioids for pain as it emerges, but the doses are so much smaller. He's actually working again. I've just been really proud of him.”
Anderson says he and his team often talk about “being greedy for our patients.”
“We want them obviously to stay away from using illicit opioids, but we want a lot more for them than that. We want them to be reunited with their kids. We want them to get and stay in safe and comfortable housing. We want them to get their jobs back.”
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