(editorial by Timothy Lepak, President, NAABT,Inc.)
Without being overdramatic, people are dieing while waiting for access to a treatment that is being rationed for no reasons other than fear, ignorance, and stigma.
In some parts of the country, physicians are at their 30 patient limit, and are faced with the decisions;
“Do I discontinue one patient’s treatment (who is doing well, perhaps for the first time in years) to provide help to another patient on my waiting list, who may die without it?” Knowing that my stable patient will be placed at a higher risk of relapse than if they remain in treatment, and knowing relapse is a life risking event… doesn’t this violate my oath? Should I violate my oath, or the law?
In a physician survey conducted by SAMHSA one physician put it this way, “The government is committing malpractice with this limit”. Despite the many, more dangerous, FDA-approved drugs, including many over-the-counter drugs, no others require a physician to obtain a special DEA registration number, or have a limit on how many patients a physician can help with the treatment. All addictive opioids are prescribed without such limits, yet the medication for treating addiction to them, is restricted. The absurdity would be laughably if it was not so tragic.
Born of inaccurate stereotyping, the law was created to ease unfounded worries of neighborhood doctors’ offices becoming "pill-mills", or "methadone-like" clinics1, feared to become a source of diversion. Apparently, leaving all but 30 of the patients in need, untreated in the community, was somehow viewed as a better alternative. It is especially ironic that the government stigmatizes its own mandated delivery programs and fears duplication of them, yet fails to realize the stigma is the product of its own interference with office-based medical care, with the creation of the methadone clinic. This could have been a great opportunity to learn from previous mistakes.
So much consideration was given to prevent diversion and misuse that many of the very people the medication was intended to help have been unable to obtain it. This has lead, in one example; to a husband sharing his medication with his wife, until she can see a doctor with an opening and be treated. By limiting access to a lifesaving treatment, the 30 limit has actually created some of the diversion it was intended to prevent.2 From what I have read in the 30,000 patient posts, on our discussion board, the small amount of buprenorphine that is being diverted is being used as indicated, to get off dangerous drugs, not for misuse.2 It is important to differentiate between diversion and misuse. Although we have not seen misuse for the most part, it no doubt exists to some degree. But, buprenorphine is different from all full agonist opioids in that its properties are less desirable to someone intent on misuse. With the abundance of less-expensive street and prescription drugs, a drug that limits euphoria, blocks other opioids, and has the potential to initiate instant withdrawal, is unlikely to become a first choice of the misuser. Even when it is misused, its safety profile, ceiling and blocking effect would present less public health risk than other opioids.
Based on the favorable safety profile of this treatment, the efficacy, the reduction in crime, HIV and other diseases3,4, and the return to work statistics,4 limiting this treatment in any way contributes to the problem, not the solution. Logic and common sense must outweigh stigma, fear and ignorance to abolish this unnecessary restriction on a lifesaving treatment.
To suppress the debilitating symptoms of cravings and withdrawal, enabling the patient to engage in therapy, counseling and support, so they can implement positive long-term changes in their lives which develops into the new healthy patterns of behavior necessary to achieve sustained addiction remission. - explain -