Opioid Pain Killers Are Still Widely Prescribed. Why Not A Treatment For Opioid Addiction?

Like a lot of people sucked into the vortex of opioid addiction, Paul Bowman’s descent began with a medical procedure.

“I started using because I had surgery and I got hooked on painkillers,” said Bowman, a Quincy resident.

Years after the pain subsided, he said his doctor continued to prescribe the opioid-based medication.

His story is not unique.

There’s a clear link between the escalation in opioid pain prescriptions and the opioid epidemic — 80 percent of heroin users report that they first misused prescription opioid, such as oxycontin. Data from the Centers for Disease Control and Prevention show that in 2006, doctors wrote 215 million opioid prescriptions, a number that jumped to 255 million in 2012 — more than enough to supply every adult in the United States with a bottle of prescription pills.

But doctors are far less liberal prescribing a medication that helped Bowman stay in long term recovery: buprenorphine, also known as Suboxone.

'Nearly Miraculous'

“When I think of medications I prescribe for [chronic] illnesses in primary care ... buprenorphine is nearly miraculous,” said Laura Kehoe, a primary care physician who runs an addiction treatment clinic at Massachusetts General Hospital.

Within the medical community there’s widespread agreement that buprenorphine works, but there is debate about why, at time when the nation is gripped by an opioid crisis, less than 7 percent of doctors prescribe it. Some in the medical community say it's because doctors lack training and are reluctant to treat people with opioid addiction; others says it's because prescribing buprenorphine requires extra work.

Unnecessary Training?

While any doctor can prescribe powerful opioid painkillers, the Drug Enforcement Agency prevents doctors from prescribing buprenorphine unless they have a special waiver — something that requires eight hours of training.

Kehoe believes that training creates a barrier for physicians and other health care providers already juggling busy schedules.

"I do waiver trainings and I can tell you, eight hours for anybody to sit in one room is a lot," she said. "When other new medications hit the market, I'm not expected to sit through a waiver."

Plus, she said, buprenorphine is a safe medication and primary care doctors are well-equipped to prescribe it to manage opioid use disorder in much the same way they would prescribe insulin to manage a patient's diabetes.

“The waiver in itself just sends the message that this is a difficult illness to treat, difficult medication to prescribe, when, in fact, it’s really quite simple,” she said.

There are bills in the House of Representatives and the Senate that would eliminate the waiver training and 39 attorneys general, including Massachusetts Attorney General Maura Healey, have signed a letter of support.

'Now What Do I Do?'

The American Academy of Addiction Psychiatry offers buprenorphine waiver training at no cost to health care providers and students nationwide. CEO Kathryn Cates-Wessel said changing the law around buprenorphine would be a mistake because the training requirement isn’t what stops doctors from offering the medication.

"They're not comfortable dealing with someone with a substance abuse disorder, or addiction — it's just not in their comfort zone. They haven't been trained in that area," she said. "I’ve had doctors and other prescribers say, 'I have the waiver, now what do I do?'"

Treating opioid addiction, she said, is different than other chronic conditions — like diabetes or heart disease — because it frequently requires mental health support as well. Buprenophine alone, she said, is not the solution.

“If you don’t have access to behavioral health, it can get complicated. How do you handle it? You’ve kind of set yourself up for failure and the patient up for failure,” she said. “I’m afraid if we throw away the waiver, they’re going to miss that very thing they need — education.”

'So Much Success'

Paul Bowman appreciates both sides of the argument — a critical need both for more addiction treatment training and a life-changing medication. Whether the waiver stays or goes, he hopes more health care providers will treat addiction.

“There’s so much success that I see with Suboxone (buprenorphine),” he said, “that I think they would actually like treating people, because you see people get better.”

Correction: A previous version of this story incorrectly indicated that opioid painkillers, such as oxycontin, aren’t controlled substances. We’ve removed the error from the article.