RECOVERY TIME

Florida could see more effective opioid addiction treatment options as feds lift buprenorphine restrictions

BY MCKENNA SCHUELER

Opioid drugs have driven a surge in drug overdose deaths in recent years, both in Central Florida and across the United States.

During the COVID-19 pandemic, the annual number of overdose deaths in the United States surpassed 100,000 for the first time, surging to nearly 107,000 deaths in 2021.

About two-thirds of those deaths involved opioids — primarily illicitly procured man-made opioids, like fentanyl.

Central Florida, unfortunately, hasn’t been able to escape the national overdose crisis.

Between 2014 and 2019, opioid-involved overdose deaths in Orange County nearly doubled — from 175 to 342 deaths. And the problem worsened during the pandemic, with Orange County estimating a 70% increase in overdose deaths amid increased reports nationwide of mental health struggles, higher stress, isolation, unemployment and housing instability.

Part of the problem is a black-market drug supply that’s contaminated with forms of fentanyl, a drug that’s up to 50 times stronger than heroin.

Pharmaceutical fentanyl can be legitimately prescribed for pain management. However, illicitly manufactured versions of the drug are increasingly being found in everything from heroin to cocaine to meth, and in fake versions of prescription pills such as Xanax and Adderall.

But, for those with opioid use disorder (opioid addiction), a lack of access to effective treatment options is also a problem. And the federal government is taking notice.

Thanks to a new federal policy change, people in Central Florida and across the U.S. who live with opioid use disorder will now face one less hurdle in accessing buprenorphine, one of the most effective treatments for opioid addiction.

What’s new

In December, the feds eliminated a decades-old bureaucratic barrier known as the “X-waiver,” which healthcare providers were required to obtain in order to prescribe the medication for addiction.

Also known by its brand names Subutex or Suboxone (a combination of buprenorphine and naloxone), buprenorphine is one of three FDA-approved medications for opioid use disorder.

It’s a “gold standard” treatment that can cut in half the risk of opioid overdose and double someone’s chances of entering long-term substance use recovery.

But it’s long been difficult to access — for those who need the treatment, or for doctors to prescribe. Obtaining a waiver to do so, specifically for opioid addiction treatment, had required at least eight hours of extra training.

Now, that’s not the case.

‘This has the potential to really, really help’ Federal officials, healthcare providers and advocates say that lifting this requirement is a significant change that could expand access to a life-saving medication and help address the ongoing problem of curbing fatal overdoses and opioid misuse.

“At a time when our nation has experienced 107,000 drug overdoses and poisoning in just one year’s time, this change could not have come sooner,” Dr. Rahul Gupta, director of the White House’s Office of National Drug Control Policy, said last month. “Removing the X-waiver, a burdensome and unnecessary requirement for medical providers, is a critical step at a time when fewer than 1 in 10 Americans who need treatment can access it.”

Dr. Martin Klapheke, director of the psychiatry residency program at UCF’s College of Medicine, told Orlando Weekly this could be a “game-changer.”

“This has the potential to really, really help with the opioid crisis,” said Klapheke.

While Florida lawmakers have preferred to take a toughon-crime approach toward “addressing” the opioid crisis (with some harm reduction initiatives sprinkled in by the state), health experts and advocates say a holistic approach — addressing gaps in treatment access as well as underlying risk factors for addiction, such as trauma and housing instability — is also necessary.

Dr. Kris Smith, a clinical specialist at Orlando Regional Medical Center for internal medicine, said the federal government’s elimination of the X-waiver requirement was “an amazing step forward” that would allow more medical professionals to provide appropriate, evidence-based treatment for those previously struggling to access care.

Smith told Orlando Weekly this could be particularly important in rural and other underserved communities, where there’s historically been a lack of addiction treatment providers who’ve opted into obtaining the waiver. This includes predominantly Black and brown communities and high-poverty areas.

A 2020 study found that 40% of counties in the U.S. didn’t have a clinician waivered to prescribe buprenorphine. Methadone, another FDA-approved medication for OUD, is even more tightly regulated.

Medication treatment (with methadone, buprenorphine and/or naltrexone) for opioid addiction is the most effective option, combined with behavioral therapy and counseling, yet only 11% of people with the disorder received medication for their condition in 2020.

Smith said medication can be “key” to better recovery outcomes (including the ability to find or maintain a job) for people with OUD, and that counseling or group therapy alone hasn’t shown to be as effective in preventing relapse.

Orange County leaders have also taken this issue under consideration.

At a November meeting of Orange County’s Opioid Advisory Committee, Dr. Amy Donley, a professor of sociology at UCF, shared that a recent survey by the county found that many addiction treatment providers in Orange County, for instance, don’t offer medicationassisted treatment.

“Only half of the providers that participated [in the survey] offer it,” Donley told the committee. “And people face a lot of difficulty in accessing it.”

Expanding access to medication-assisted treatment in Orange County is one of six recommendations local experts have for working to address opioid overdose and substance misuse in the community.

Other recommendations include expanding education and prevention strategies, improving care coordination, and expanding peer community support options such as sober living, among other initiatives.

Orange County also has a pilot program that offers medication-assisted treatment, including access to buprenorphine, to people incarcerated in Orange County Jail.

About 25% of people incarcerated in the U.S. are affected by opioid use disorder. Incarcerated people with substance use disorders are at a significantly higher risk for relapse and fatal overdose upon release, but just a fraction of jails offer this kind of care.

How does buprenorphine help with opioid addiction?

Buprenorphine is what’s known as a “partial agonist” opioid. It can help with pain management. But it can also treat opioid use disorder.

Compared to full agonists, like oxycodone (OxyContin) and fentanyl, buprenorphine has a lower level of physical dependence, lower abuse potential, and is safer than full agonists even in higher doses, due to its ceiling effect.

Importantly, it can help relieve highly uncomfortable symptoms associated with opioid withdrawal, including powerful drug cravings.

Withdrawal, Dr. Smith said, is a high risk factor for relapse. Someone experiencing withdrawal — nausea, vomiting, muscle and joint pain, anxiety and insomnia — if unable to access adequate relief, may return to their opioid use.

Just to feel normal. Just to feel OK.

Buprenorphine does have a risk for misuse. But that’s true of virtually every drug. Moreover, research suggests that buprenorphine misuse has decreased in recent years, even with an increase in prescriptions.

A recent study from the National Institutes of Health also found that relaxed restrictions on prescribing buprenorphine during the COVID-19 pandemic — not quite as expansive as the recent change — did not lead to an increase in overdose deaths.

Both Dr. Smith and UCF professor Dr. Klapheke emphasized that it’s important to think of opioid use disorder like any other medical disease, such as hypertension.

You go to a doctor, they assess whether medication is the right option for you, and you take that medication — maybe for months, for years, or for however long you and your doctor determine is necessary.

Experts typically recommend that medicationassisted treatment be provided for a minimum of 12 months, to be effective, but medication may also be taken for years.

This can be hard for some people to wrap their heads around. Myths and stigma surrounding drug addiction — and pharmacological treatments for it — can also be a barrier to care.

Addiction experts, for instance, stress that MAT is not “trading” one addiction for another.

Cristopher Carlson, a primary care social worker at the James A. Haley Veterans’ Hospital in Tampa, told Orlando Weekly this new policy change could help to further normalize MAT.

“I’m hoping eliminating the waiver will reduce stigma and expand access to a medication many people could benefit from,” said Carlson.

“I think it’s important to recognize that taking a medication like buprenorphine for opioid use is really not that different from taking medication for high blood pressure or diabetes.

“It’s basic stuff.”

Accessing buprenorphine across all levels of care

Another problem this new federal policy change could help to solve is a disruption in care.

Before, buprenorphine could only be prescribed by clinicians who’d undergone the extra training to obtain the special waiver, or clinicians who’d gone through with requesting a waiver when that requirement was loosened in 2021.

Sometimes this meant that those who’d gotten buprenorphine through, say, an inpatient provider (e.g., a hospital), would lose that if they transitioned to outpatient and weren’t able to find an outpatient provider right away who could help them continue their treatment. Smith said she saw this in her practice at ORMC.

Carlson said he saw this go both ways.

“I’ve seen people who were prescribed Suboxone [a brand version of buprenorphine] as outpatients involuntarily admitted to psychiatric hospitals, only to learn not a single psychiatrist on staff had the license to continue prescribing it. Either that or the pharmacy didn’t supply it,” Carlson told Orlando Weekly

“It was a mess. Now that the waiver is eliminated, hopefully these kinds of disruptions start to disappear.”

Can just anyone prescribe buprenorphine now?

Yes, but no. This option will be available for any healthcare provider who’s registered with the DEA, which is similarly required for prescribing other controlled substances.

During the pandemic, the federal government did begin to loosen prescribing requirements, as fatal overdoses soared, but had capped the number of patients a provider could treat at a time to 30. With this new change, that cap is no longer in place.

Is buprenorphine expensive?

Cost is one of the most common barriers to medical and behavioral healthcare in the United States. (Too bad we don’t have a single-payer healthcare system, like Medicare for All.) And buprenorphine can be expensive, if you don’t have health insurance.

But the good news is, according to Smith, many treatment providers these days have access to grants. Those grants, some of which come from the federal government, can help cover the cost of addiction medication for those who are uninsured and/or who are low-income.

That way, the cost of the medication may be covered in full, or it may be available on a sliding scale, depending on your level of income.

This isn’t true everywhere, but Smith said this is at least true for ORMC, which also receives grant funding from Florida Blue to help bridge those gaps.

Where can I find help for opioid addiction?

If you’re looking for opioid addiction treatment for yourself or a loved one, the best way to find quality treatment is through the Substance Abuse and Mental Health Services Administration.

You can access SAMHSA’s treatment locator online, or call their National Helpline at 1-800662-HELP (4357). That non-emergency treatment referral helpline is available 24/7, year-round.

Orange County also has a list of treatment resources, including social services, on its website (ocfl.net) in the Families, Health and Social Services section.

mschueler@orlandoweekly.com