Hello Buprenorphine, Step Into My Practice

After years of alarming increases in opioid overdose deaths, the U.S. finally saw a 1-year decline from 84,000 to 81,000 in 2023. While the marginal drop is encouraging, we cannot rest on this achievement or count on it to continue. Too many people are still dying, and much more needs to be done. The question is what?

A crucial first step is to overcome widespread physician hesitancy to prescribe buprenorphine, a medicine that for years has proven successful in curbing opioid use disorder (OUD) and reducing the risk of overdose. Despite robust scientific evidence, many physicians and advanced practice providers don’t prescribe the drug, commonly known as “bupe.” Several factors contribute to prescriber hesitancy, including general discomfort treating addiction, siloing of addiction care outside of the traditional medical setting, burdensome requirements that previously mandated a separate prescribing license for buprenorphine, and ongoing misunderstanding of the role of medication in treating OUD.

Addiction medicine training is often lacking in medical school, leaving some physicians without the knowledge to counter the stereotypes, stigma, and misunderstandings surrounding addiction treatment. This is especially true for medication treatment of OUD. Despite the growing recognition of addiction as a public health crisis, many in the medical community may have been exposed to the general societal myths of addiction being an issue of bad behavior or limited willpower. If you have been exposed to those notions, then the idea of medication may seem incongruous as a treatment.

Worse still, medications like buprenorphine can be perceived as an “easy way” or a “crutch” in a dominant narrative that is framed around “tough love” and “hitting rock bottom.” Buprenorphine is especially vulnerable to criticism because it acts on the same brain receptors that other opioids do and oftentimes, use of medicated treatment is seen as “replacing one addiction with another.” However, there is a critical distinction between taking a medication daily to maintain health and compulsively using a substance despite harmful consequences.

If addiction were synonymous with a daily medication regimen, then millions of individuals treated with conditions like high blood pressure, diabetes, depression, and thyroid disease would be considered “addicted.”

As a second step, we need physicians to see and treat substance use disorder as a chronic condition, like diabetes or hypertension. Substance use disorder is just one aspect of a patient’s medical history; it does not define them. The medical community must address all the health needs of an individual with substance use disorder — just as it would for any other condition — using holistic, wraparound services within the traditional medical setting.

The third step is to educate physicians about the significant progress made in eliminating red tape previously tied to prescribing buprenorphine. Many still believe that the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Drug Enforcement Administration (DEA) maintain strict controls on who can prescribe buprenorphine. But in fact, in 2022, the Mainstreaming Addiction Treatment Act eliminated the X-waiver, a complicated and time-consuming requirement physicians had to complete in order to prescribe the medication.

Months later, the DEA announced its full support for the elimination of the X-waiver. This law, along with previous HHS guidance, eliminated patient caps placed on physicians and many other hurdles to prescribing. Today, a standard DEA registration number is all that’s required to prescribe buprenorphine. When the X-waiver was eliminated, prescribing became much easier, yet physician uncertainty and stigma remain.

Medical societies, health systems, and public health agencies must join forces to help normalize conversations about substance use between patients and their doctors. Let’s make it acceptable for a patient to say, “Tell me about bupe,” without fear of judgment or shame.

Finally, the medical community must confront the ongoing inequity in access to quality substance use care. Research shows that Black, Latino, and Native American people do not receive the same access to buprenorphine as white patients. This comes at a time when overdose death rates in the Black and Native American communities have increased steadily.

In 2020, opioid deaths in Black individuals exceeded those among white persons for the first time in more than 20 years. And while Latino rates of overdose remain below white and Black persons, overdose rates in the Latino population increased by 40% between 2019 and 2021. We can celebrate the 1-year decline in overdose deaths, but to sustain meaningful progress, the medical community must recognize and tackle these inequities in care.

At the health system I work within, we’ve approached these challenges head on through our “Bridge Clinics.” The clinics are designed to provide low-threshold, on-demand access to medical experts in addiction treatment, including physicians, nurse practitioners, registered nurses, psychologists, recovery coaches, and resource specialists. Our team provides a person-centered approach to treatment that includes access to medication like buprenorphine, counseling, peer support, community referrals, treatment of co-occurring medical and mental health conditions, and education.

Though buprenorphine can be started in any care setting, our team can initiate buprenorphine at any of our four Bridge Clinics across Massachusetts while bridging patients to long-term providers. We meet our patients where they are on their recovery journey — with compassion, not judgment.

This approach has been successful, and we continue to refine our methods as we learn more from our patients, their evolving challenges, and their successes. We recognize, however, that what works in Massachusetts may not be applicable nationwide. Each hospital and medical system must create pathways to treatment tailored to their community’s unique needs. Treatment should be personalized and based on the needs, preferences, and history of the individual.

Opioid overdose deaths remain unacceptably high across our country, but we have a safe, proven recovery medication in our hands. It is time for the medical community to embrace buprenorphine and increase its use. To achieve real, sustained progress in combating the overdose crisis, we must provide education, challenge myths, incentivize change, and make it as easy as possible for providers to offer this life-saving medication to those in need.

Sarah Wakeman, MD, is medical director for Substance Use Disorder at Mass General Brigham, medical director for the Mass General Hospital Substance Use Disorder Initiative, and an associate professor of medicine at Harvard Medical School in Boston.

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