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The X-waiver is dead
In 2016, when Erin Schanning lost her brother Ethan to an overdose, she wanted to know what could have been done to have helped him. Ethan, who had struggled with opioids since getting a prescription for the drugs after a dental procedure in middle school, had tried dozens of treatments. But at the age of 30, he was gone.
“After my brother died, I started researching and was surprised to learn that there were many evidence-based ways to treat substance use disorder that he hadn’t had access to, even though he had doggedly pursued treatment,” Ms. Schanning told me in an interview. One of those treatments, buprenorphine, is one of the most effective tools that health care providers have to treat opioid use disorder. A partial opioid agonist, it reduces cravings and prevents overdose, decreasing mortality more effectively than almost any medication for any disease. Yet most providers have never prescribed it.
That may be about to change. The special license to prescribe the medication, commonly known as the “X-waiver,” was officially eliminated as part of the passage of the Mainstreaming Addiction Treatment (MAT) Act. Immediately, following the passage of the Act, any provider with a DEA license became eligible to prescribe buprenorphine to treat opioid use disorder, and limits on the number of patients they could treat were eliminated.
Previously, buprenorphine, which has a better safety profile than almost any other prescription opioid because of its ceiling effect on respiratory depression,nonetheless required providers to obtain a special license to prescribe it, and – prior to an executive order from the Biden administration – 8 to 24 hours of training to do so. This led to a misconception that buprenorphine was dangerous, and created barriers for treatment during the worst overdose crisis in our country’s history. More than 110,00 overdose deaths occurred in 2021, representing a 468% increase in the last 2 decades.
Along with the MAT Act, the Medication Access and Training Expansion Act was passed in the same spending bill, requiring all prescribers who obtain a DEA license to do 8 hours of training on the treatment of substance use disorders. According to the Act, addiction specialty societies will have a role in creating trainings. Medical schools and residencies will also be able to fulfill this requirement with a “comprehensive” curriculum that covers all approved medications for the treatment of substance use disorders.
The DEA has not yet confirmed what training will be accepted, according to the Chief Medical Officer of the Substance Abuse and Mental Health Services Administration, Neeraj Gandotra, MD, who spoke to me in an interview. However, it is required to do so by April 5, 2023. Dr. Gandotra also emphasized that state and local laws, as well as insurance requirements, remain in place, and may place other constraints on prescribing. According to the Act, this new rule will be in effect by June 2023.
As an addiction medicine specialist and longtime buprenorphine prescriber, I am excited about these changes but wary of lingering resistance among health care providers. Will providers who have chosen not to get an X-waiver now look for another reason to not treat patients with substance use disorders?
Ms. Schanning remains hopeful. “I’m incredibly optimistic that health care providers are going to learn about buprenorphine and prescribe it to patients, and that patients are going to start asking about this medication,” she told me. “Seven in 10 providers say that they do feel an obligation to treat their patients with [opioid use disorder], but the federal government has made it very difficult to do so.”
Now with the X-waiver gone, providers and patients may be able to push for a long overdue shift in how we treat and conceptualize substance use disorders, she noted.
“Health care providers need to recognize substance use disorder as a medical condition that deserves treatment, and to speak about it like a medical condition,” Ms. Schanning said, by, for instance, moving away from using words such as “abuse” and “clean” and, instead, talking about treatable substance use disorders that can improve with evidence-based care, such as buprenorphine and methadone. “We also need to share stories of success and hope with people,” she added. “Once you’ve seen how someone can be transformed by treatment, it’s really difficult to say that substance use disorder is a character flaw, or their fault.”
A patient-centered approach
Over the past decade of practicing medicine, I have experienced this transformation personally. In residency, I believed that people had to be ready for help, to stop using, to change. I failed to recognize that many of those same people were asking me for help, and I wasn’t offering what they needed. The person who had to change was me.
As I moved toward a patient-centered approach, lowering barriers to starting and remaining in treatment, and collaborating with teams that could meet people wherever they might be, addictions became the most rewarding part of my practice.
I have never had more people thank me spontaneously and deeply for the care I provide. Plus, I have never seen a more profound change in the students I work with than when they witness someone with a substance use disorder offered treatment that works.
The X-waiver was not the only barrier to care, and the overdose crisis is not slowing down. But maybe with a new tool widely accessible, more of us will be ready to help.
Dr. Poorman is board certified in internal medicine and addiction medicine, assistant professor of medicine, University of Illinois at Chicago, and provides primary care and addiction services in Chicago. Her views do not necessarily reflect the views of her employer. She has reported no relevant disclosures, and she serves on the editorial advisory board of Internal Medicine News.
In 2016, when Erin Schanning lost her brother Ethan to an overdose, she wanted to know what could have been done to have helped him. Ethan, who had struggled with opioids since getting a prescription for the drugs after a dental procedure in middle school, had tried dozens of treatments. But at the age of 30, he was gone.
“After my brother died, I started researching and was surprised to learn that there were many evidence-based ways to treat substance use disorder that he hadn’t had access to, even though he had doggedly pursued treatment,” Ms. Schanning told me in an interview. One of those treatments, buprenorphine, is one of the most effective tools that health care providers have to treat opioid use disorder. A partial opioid agonist, it reduces cravings and prevents overdose, decreasing mortality more effectively than almost any medication for any disease. Yet most providers have never prescribed it.
That may be about to change. The special license to prescribe the medication, commonly known as the “X-waiver,” was officially eliminated as part of the passage of the Mainstreaming Addiction Treatment (MAT) Act. Immediately, following the passage of the Act, any provider with a DEA license became eligible to prescribe buprenorphine to treat opioid use disorder, and limits on the number of patients they could treat were eliminated.
Previously, buprenorphine, which has a better safety profile than almost any other prescription opioid because of its ceiling effect on respiratory depression,nonetheless required providers to obtain a special license to prescribe it, and – prior to an executive order from the Biden administration – 8 to 24 hours of training to do so. This led to a misconception that buprenorphine was dangerous, and created barriers for treatment during the worst overdose crisis in our country’s history. More than 110,00 overdose deaths occurred in 2021, representing a 468% increase in the last 2 decades.
Along with the MAT Act, the Medication Access and Training Expansion Act was passed in the same spending bill, requiring all prescribers who obtain a DEA license to do 8 hours of training on the treatment of substance use disorders. According to the Act, addiction specialty societies will have a role in creating trainings. Medical schools and residencies will also be able to fulfill this requirement with a “comprehensive” curriculum that covers all approved medications for the treatment of substance use disorders.
The DEA has not yet confirmed what training will be accepted, according to the Chief Medical Officer of the Substance Abuse and Mental Health Services Administration, Neeraj Gandotra, MD, who spoke to me in an interview. However, it is required to do so by April 5, 2023. Dr. Gandotra also emphasized that state and local laws, as well as insurance requirements, remain in place, and may place other constraints on prescribing. According to the Act, this new rule will be in effect by June 2023.
As an addiction medicine specialist and longtime buprenorphine prescriber, I am excited about these changes but wary of lingering resistance among health care providers. Will providers who have chosen not to get an X-waiver now look for another reason to not treat patients with substance use disorders?
Ms. Schanning remains hopeful. “I’m incredibly optimistic that health care providers are going to learn about buprenorphine and prescribe it to patients, and that patients are going to start asking about this medication,” she told me. “Seven in 10 providers say that they do feel an obligation to treat their patients with [opioid use disorder], but the federal government has made it very difficult to do so.”
Now with the X-waiver gone, providers and patients may be able to push for a long overdue shift in how we treat and conceptualize substance use disorders, she noted.
“Health care providers need to recognize substance use disorder as a medical condition that deserves treatment, and to speak about it like a medical condition,” Ms. Schanning said, by, for instance, moving away from using words such as “abuse” and “clean” and, instead, talking about treatable substance use disorders that can improve with evidence-based care, such as buprenorphine and methadone. “We also need to share stories of success and hope with people,” she added. “Once you’ve seen how someone can be transformed by treatment, it’s really difficult to say that substance use disorder is a character flaw, or their fault.”
A patient-centered approach
Over the past decade of practicing medicine, I have experienced this transformation personally. In residency, I believed that people had to be ready for help, to stop using, to change. I failed to recognize that many of those same people were asking me for help, and I wasn’t offering what they needed. The person who had to change was me.
As I moved toward a patient-centered approach, lowering barriers to starting and remaining in treatment, and collaborating with teams that could meet people wherever they might be, addictions became the most rewarding part of my practice.
I have never had more people thank me spontaneously and deeply for the care I provide. Plus, I have never seen a more profound change in the students I work with than when they witness someone with a substance use disorder offered treatment that works.
The X-waiver was not the only barrier to care, and the overdose crisis is not slowing down. But maybe with a new tool widely accessible, more of us will be ready to help.
Dr. Poorman is board certified in internal medicine and addiction medicine, assistant professor of medicine, University of Illinois at Chicago, and provides primary care and addiction services in Chicago. Her views do not necessarily reflect the views of her employer. She has reported no relevant disclosures, and she serves on the editorial advisory board of Internal Medicine News.
In 2016, when Erin Schanning lost her brother Ethan to an overdose, she wanted to know what could have been done to have helped him. Ethan, who had struggled with opioids since getting a prescription for the drugs after a dental procedure in middle school, had tried dozens of treatments. But at the age of 30, he was gone.
“After my brother died, I started researching and was surprised to learn that there were many evidence-based ways to treat substance use disorder that he hadn’t had access to, even though he had doggedly pursued treatment,” Ms. Schanning told me in an interview. One of those treatments, buprenorphine, is one of the most effective tools that health care providers have to treat opioid use disorder. A partial opioid agonist, it reduces cravings and prevents overdose, decreasing mortality more effectively than almost any medication for any disease. Yet most providers have never prescribed it.
That may be about to change. The special license to prescribe the medication, commonly known as the “X-waiver,” was officially eliminated as part of the passage of the Mainstreaming Addiction Treatment (MAT) Act. Immediately, following the passage of the Act, any provider with a DEA license became eligible to prescribe buprenorphine to treat opioid use disorder, and limits on the number of patients they could treat were eliminated.
Previously, buprenorphine, which has a better safety profile than almost any other prescription opioid because of its ceiling effect on respiratory depression,nonetheless required providers to obtain a special license to prescribe it, and – prior to an executive order from the Biden administration – 8 to 24 hours of training to do so. This led to a misconception that buprenorphine was dangerous, and created barriers for treatment during the worst overdose crisis in our country’s history. More than 110,00 overdose deaths occurred in 2021, representing a 468% increase in the last 2 decades.
Along with the MAT Act, the Medication Access and Training Expansion Act was passed in the same spending bill, requiring all prescribers who obtain a DEA license to do 8 hours of training on the treatment of substance use disorders. According to the Act, addiction specialty societies will have a role in creating trainings. Medical schools and residencies will also be able to fulfill this requirement with a “comprehensive” curriculum that covers all approved medications for the treatment of substance use disorders.
The DEA has not yet confirmed what training will be accepted, according to the Chief Medical Officer of the Substance Abuse and Mental Health Services Administration, Neeraj Gandotra, MD, who spoke to me in an interview. However, it is required to do so by April 5, 2023. Dr. Gandotra also emphasized that state and local laws, as well as insurance requirements, remain in place, and may place other constraints on prescribing. According to the Act, this new rule will be in effect by June 2023.
As an addiction medicine specialist and longtime buprenorphine prescriber, I am excited about these changes but wary of lingering resistance among health care providers. Will providers who have chosen not to get an X-waiver now look for another reason to not treat patients with substance use disorders?
Ms. Schanning remains hopeful. “I’m incredibly optimistic that health care providers are going to learn about buprenorphine and prescribe it to patients, and that patients are going to start asking about this medication,” she told me. “Seven in 10 providers say that they do feel an obligation to treat their patients with [opioid use disorder], but the federal government has made it very difficult to do so.”
Now with the X-waiver gone, providers and patients may be able to push for a long overdue shift in how we treat and conceptualize substance use disorders, she noted.
“Health care providers need to recognize substance use disorder as a medical condition that deserves treatment, and to speak about it like a medical condition,” Ms. Schanning said, by, for instance, moving away from using words such as “abuse” and “clean” and, instead, talking about treatable substance use disorders that can improve with evidence-based care, such as buprenorphine and methadone. “We also need to share stories of success and hope with people,” she added. “Once you’ve seen how someone can be transformed by treatment, it’s really difficult to say that substance use disorder is a character flaw, or their fault.”
A patient-centered approach
Over the past decade of practicing medicine, I have experienced this transformation personally. In residency, I believed that people had to be ready for help, to stop using, to change. I failed to recognize that many of those same people were asking me for help, and I wasn’t offering what they needed. The person who had to change was me.
As I moved toward a patient-centered approach, lowering barriers to starting and remaining in treatment, and collaborating with teams that could meet people wherever they might be, addictions became the most rewarding part of my practice.
I have never had more people thank me spontaneously and deeply for the care I provide. Plus, I have never seen a more profound change in the students I work with than when they witness someone with a substance use disorder offered treatment that works.
The X-waiver was not the only barrier to care, and the overdose crisis is not slowing down. But maybe with a new tool widely accessible, more of us will be ready to help.
Dr. Poorman is board certified in internal medicine and addiction medicine, assistant professor of medicine, University of Illinois at Chicago, and provides primary care and addiction services in Chicago. Her views do not necessarily reflect the views of her employer. She has reported no relevant disclosures, and she serves on the editorial advisory board of Internal Medicine News.
The lives of drug users are more important than stopping drug use
One quiet afternoon at a mobile outreach clinic, where I had been working on the West Side of Chicago, a young man without a home to go to, and clothes he kept as clean as he could, came to get a refill of buprenorphine. The drug, which works on the same opioid receptors as heroin, was helping him feel normal. It was also probably helping to keep him alive, as a study found that taking it after an overdose was associated with a one-third reduction in all-cause mortality.
He was still using drugs, but now only a few days a week instead of multiple times a day. He had put on some weight and looked visibly healthier.
I gave him his prescription and thanked him for coming back. As he got up to leave, he turned to our outreach team and said, “Thank you for being here and caring about us. Because a lot of people don’t. They don’t care if we live or die.”
But a lot of people do care and are still failing him and others who use drugs. When I first started treating addictions, I was taught to cut people like him off treatment. We could give patients a medication, but they had to follow the rules, first and foremost to stop using drugs. Keep using, even if you were using less and your health was improving, and I would have to dismiss you from the practice. This was the kind of “tough love” that many doctors have been taught, and are, in many cases, still being taught today. Even though we know that this approach does not work.
For too long, doctors, nurses, caregivers, and the broader American public have favored abstinence only treatment, criminalization, and prohibition. The proof that this approach does not work is in the spectacular overdose crisis we are experiencing in this country, as CDC data documents. While we continue to blame drugs like fentanyl and methamphetamine (and thirty years ago, crack and heroin), we fail to see how our approach contributes to these overdose deaths.
For instance, treating with buprenorphine or methadone was associated with reductions in overdose and serious opioid-related acute care use compared with detox alone. But only one in three centers offer these medications, the gold standard of care. We continue to imprison people who use drugs, even though we have known for 15 years that the risk of overdose is exponentially higher in the first few weeks after people leave prison.
Patients who use opioids safely for decades are also arbitrarily being forced off their prescriptions because too many clinicians equate opioid use with opioid addiction, despite the fact that opioid tapering was associated with increased rates of overdose. And prohibition has led to a change in the drug supply that is now dominated by methamphetamine and fentanyl, substances far more deadly than the ones we demonized and seized decades ago.
We have tried and failed to rid the country of many drugs. We never will. Human beings will seek mind-altering substances, from caffeine to alcohol to hallucinogens. But we can stop the grim massacre of people who use drugs. We have the tools. What we lack is moral clarity.
In lecture after lecture of physicians and medical students, I hear the refrain that patients are not often “ready” for treatment. There’s nothing that doctors can do, they say, if the patient doesn’t want help. Yet they do not examine why that may be. Are we offering the help that they need? Time and again I have seen that if we meet people where they are, we can help virtually anyone.
Tools for fighting the opioid crisis
The reason our policies have failed is because we have not confronted a simple truth: We must care more about saving and improving the lives of people who use drugs than stopping drug use. With that framework, the approach is clear and multifactorial. First, we must make methadone treatment less draconian. Methadone, like buprenorphine, has been associated with a large reduction in all-cause mortality for people who have a history of overdose.
In this country, to access it, however, you must go to a clinic daily for the first 90 days of treatment and jump through hoops that often make it impossible to have a job and accomplish other goals. Other countries have safely moved methadone to primary care offices, and so should we. The other main drug for opioid addiction, buprenorphine, requires a special license to prescribe, even though it is far safer than other opioids that any physician can prescribe. This requirement has been weakened, but it should be removed entirely.
Moreover, the DEA conducts regular audits of buprenorphine prescribers in an effort to prevent diversion, discouraging doctors from prescribing it. This despite the fact that it is almost impossible to overdose on buprenorphine alone, and a study suggests that diversion of buprenorphine is associated with a lower overdose risk in a community by making the medication available to more people who can benefit.
Treatment is not the only way we can help people using drugs. Naloxone, an overdose rescue drug, should be available in every first aid kit and free at pharmacies without a prescription. Clean needles and pipes for people who use can help prevent infections, potentially mitigating the severity of outbreaks. Overdose prevention sites, where people can safely use, should be opened across the country.
We need accessible drug testing so people do not accidentally overdose and so they can know what they are using. We should stop sending people to jail for drug use when we know that it is too often tantamount to a death sentence, and offer effective medical treatment to anyone who is incarcerated.
All these interventions remain controversial within medicine and in the larger culture. If our metric, however, is lives saved and harm avoided, these are sure-fire approaches.
Right now, I am focused on clinical care and changing the culture of medicine, where we have opportunities to help but too often do harm instead. The impact of a shift in mentality would be huge, because we would realize there is no one we cannot help, only millions of people we do not listen to. But this is a national crisis and requires a national response. Until we are clear that our goal should and must be to stem the mounting deaths and harms above all else, we will continue to fail.
Dr. Poorman is board certified in internal medicine and addiction medicine, assistant professor of medicine, University of Illinois at Chicago, and provides primary care and addiction services in Chicago. Her views do not necessarily reflect the views of her employer. She has reported no relevant disclosures.
One quiet afternoon at a mobile outreach clinic, where I had been working on the West Side of Chicago, a young man without a home to go to, and clothes he kept as clean as he could, came to get a refill of buprenorphine. The drug, which works on the same opioid receptors as heroin, was helping him feel normal. It was also probably helping to keep him alive, as a study found that taking it after an overdose was associated with a one-third reduction in all-cause mortality.
He was still using drugs, but now only a few days a week instead of multiple times a day. He had put on some weight and looked visibly healthier.
I gave him his prescription and thanked him for coming back. As he got up to leave, he turned to our outreach team and said, “Thank you for being here and caring about us. Because a lot of people don’t. They don’t care if we live or die.”
But a lot of people do care and are still failing him and others who use drugs. When I first started treating addictions, I was taught to cut people like him off treatment. We could give patients a medication, but they had to follow the rules, first and foremost to stop using drugs. Keep using, even if you were using less and your health was improving, and I would have to dismiss you from the practice. This was the kind of “tough love” that many doctors have been taught, and are, in many cases, still being taught today. Even though we know that this approach does not work.
For too long, doctors, nurses, caregivers, and the broader American public have favored abstinence only treatment, criminalization, and prohibition. The proof that this approach does not work is in the spectacular overdose crisis we are experiencing in this country, as CDC data documents. While we continue to blame drugs like fentanyl and methamphetamine (and thirty years ago, crack and heroin), we fail to see how our approach contributes to these overdose deaths.
For instance, treating with buprenorphine or methadone was associated with reductions in overdose and serious opioid-related acute care use compared with detox alone. But only one in three centers offer these medications, the gold standard of care. We continue to imprison people who use drugs, even though we have known for 15 years that the risk of overdose is exponentially higher in the first few weeks after people leave prison.
Patients who use opioids safely for decades are also arbitrarily being forced off their prescriptions because too many clinicians equate opioid use with opioid addiction, despite the fact that opioid tapering was associated with increased rates of overdose. And prohibition has led to a change in the drug supply that is now dominated by methamphetamine and fentanyl, substances far more deadly than the ones we demonized and seized decades ago.
We have tried and failed to rid the country of many drugs. We never will. Human beings will seek mind-altering substances, from caffeine to alcohol to hallucinogens. But we can stop the grim massacre of people who use drugs. We have the tools. What we lack is moral clarity.
In lecture after lecture of physicians and medical students, I hear the refrain that patients are not often “ready” for treatment. There’s nothing that doctors can do, they say, if the patient doesn’t want help. Yet they do not examine why that may be. Are we offering the help that they need? Time and again I have seen that if we meet people where they are, we can help virtually anyone.
Tools for fighting the opioid crisis
The reason our policies have failed is because we have not confronted a simple truth: We must care more about saving and improving the lives of people who use drugs than stopping drug use. With that framework, the approach is clear and multifactorial. First, we must make methadone treatment less draconian. Methadone, like buprenorphine, has been associated with a large reduction in all-cause mortality for people who have a history of overdose.
In this country, to access it, however, you must go to a clinic daily for the first 90 days of treatment and jump through hoops that often make it impossible to have a job and accomplish other goals. Other countries have safely moved methadone to primary care offices, and so should we. The other main drug for opioid addiction, buprenorphine, requires a special license to prescribe, even though it is far safer than other opioids that any physician can prescribe. This requirement has been weakened, but it should be removed entirely.
Moreover, the DEA conducts regular audits of buprenorphine prescribers in an effort to prevent diversion, discouraging doctors from prescribing it. This despite the fact that it is almost impossible to overdose on buprenorphine alone, and a study suggests that diversion of buprenorphine is associated with a lower overdose risk in a community by making the medication available to more people who can benefit.
Treatment is not the only way we can help people using drugs. Naloxone, an overdose rescue drug, should be available in every first aid kit and free at pharmacies without a prescription. Clean needles and pipes for people who use can help prevent infections, potentially mitigating the severity of outbreaks. Overdose prevention sites, where people can safely use, should be opened across the country.
We need accessible drug testing so people do not accidentally overdose and so they can know what they are using. We should stop sending people to jail for drug use when we know that it is too often tantamount to a death sentence, and offer effective medical treatment to anyone who is incarcerated.
All these interventions remain controversial within medicine and in the larger culture. If our metric, however, is lives saved and harm avoided, these are sure-fire approaches.
Right now, I am focused on clinical care and changing the culture of medicine, where we have opportunities to help but too often do harm instead. The impact of a shift in mentality would be huge, because we would realize there is no one we cannot help, only millions of people we do not listen to. But this is a national crisis and requires a national response. Until we are clear that our goal should and must be to stem the mounting deaths and harms above all else, we will continue to fail.
Dr. Poorman is board certified in internal medicine and addiction medicine, assistant professor of medicine, University of Illinois at Chicago, and provides primary care and addiction services in Chicago. Her views do not necessarily reflect the views of her employer. She has reported no relevant disclosures.
One quiet afternoon at a mobile outreach clinic, where I had been working on the West Side of Chicago, a young man without a home to go to, and clothes he kept as clean as he could, came to get a refill of buprenorphine. The drug, which works on the same opioid receptors as heroin, was helping him feel normal. It was also probably helping to keep him alive, as a study found that taking it after an overdose was associated with a one-third reduction in all-cause mortality.
He was still using drugs, but now only a few days a week instead of multiple times a day. He had put on some weight and looked visibly healthier.
I gave him his prescription and thanked him for coming back. As he got up to leave, he turned to our outreach team and said, “Thank you for being here and caring about us. Because a lot of people don’t. They don’t care if we live or die.”
But a lot of people do care and are still failing him and others who use drugs. When I first started treating addictions, I was taught to cut people like him off treatment. We could give patients a medication, but they had to follow the rules, first and foremost to stop using drugs. Keep using, even if you were using less and your health was improving, and I would have to dismiss you from the practice. This was the kind of “tough love” that many doctors have been taught, and are, in many cases, still being taught today. Even though we know that this approach does not work.
For too long, doctors, nurses, caregivers, and the broader American public have favored abstinence only treatment, criminalization, and prohibition. The proof that this approach does not work is in the spectacular overdose crisis we are experiencing in this country, as CDC data documents. While we continue to blame drugs like fentanyl and methamphetamine (and thirty years ago, crack and heroin), we fail to see how our approach contributes to these overdose deaths.
For instance, treating with buprenorphine or methadone was associated with reductions in overdose and serious opioid-related acute care use compared with detox alone. But only one in three centers offer these medications, the gold standard of care. We continue to imprison people who use drugs, even though we have known for 15 years that the risk of overdose is exponentially higher in the first few weeks after people leave prison.
Patients who use opioids safely for decades are also arbitrarily being forced off their prescriptions because too many clinicians equate opioid use with opioid addiction, despite the fact that opioid tapering was associated with increased rates of overdose. And prohibition has led to a change in the drug supply that is now dominated by methamphetamine and fentanyl, substances far more deadly than the ones we demonized and seized decades ago.
We have tried and failed to rid the country of many drugs. We never will. Human beings will seek mind-altering substances, from caffeine to alcohol to hallucinogens. But we can stop the grim massacre of people who use drugs. We have the tools. What we lack is moral clarity.
In lecture after lecture of physicians and medical students, I hear the refrain that patients are not often “ready” for treatment. There’s nothing that doctors can do, they say, if the patient doesn’t want help. Yet they do not examine why that may be. Are we offering the help that they need? Time and again I have seen that if we meet people where they are, we can help virtually anyone.
Tools for fighting the opioid crisis
The reason our policies have failed is because we have not confronted a simple truth: We must care more about saving and improving the lives of people who use drugs than stopping drug use. With that framework, the approach is clear and multifactorial. First, we must make methadone treatment less draconian. Methadone, like buprenorphine, has been associated with a large reduction in all-cause mortality for people who have a history of overdose.
In this country, to access it, however, you must go to a clinic daily for the first 90 days of treatment and jump through hoops that often make it impossible to have a job and accomplish other goals. Other countries have safely moved methadone to primary care offices, and so should we. The other main drug for opioid addiction, buprenorphine, requires a special license to prescribe, even though it is far safer than other opioids that any physician can prescribe. This requirement has been weakened, but it should be removed entirely.
Moreover, the DEA conducts regular audits of buprenorphine prescribers in an effort to prevent diversion, discouraging doctors from prescribing it. This despite the fact that it is almost impossible to overdose on buprenorphine alone, and a study suggests that diversion of buprenorphine is associated with a lower overdose risk in a community by making the medication available to more people who can benefit.
Treatment is not the only way we can help people using drugs. Naloxone, an overdose rescue drug, should be available in every first aid kit and free at pharmacies without a prescription. Clean needles and pipes for people who use can help prevent infections, potentially mitigating the severity of outbreaks. Overdose prevention sites, where people can safely use, should be opened across the country.
We need accessible drug testing so people do not accidentally overdose and so they can know what they are using. We should stop sending people to jail for drug use when we know that it is too often tantamount to a death sentence, and offer effective medical treatment to anyone who is incarcerated.
All these interventions remain controversial within medicine and in the larger culture. If our metric, however, is lives saved and harm avoided, these are sure-fire approaches.
Right now, I am focused on clinical care and changing the culture of medicine, where we have opportunities to help but too often do harm instead. The impact of a shift in mentality would be huge, because we would realize there is no one we cannot help, only millions of people we do not listen to. But this is a national crisis and requires a national response. Until we are clear that our goal should and must be to stem the mounting deaths and harms above all else, we will continue to fail.
Dr. Poorman is board certified in internal medicine and addiction medicine, assistant professor of medicine, University of Illinois at Chicago, and provides primary care and addiction services in Chicago. Her views do not necessarily reflect the views of her employer. She has reported no relevant disclosures.