Healthcare officials in Maine say it is too early to tell how a decision by federal regulators to remove a training requirement for physicians to prescribe buprenorphine for opioid addiction might affect opioid dependency treatment in Maine. Credit: Toby Talbot / AP

The federal government made it easier for physicians to prescribe a drug used to treat opioid use disorder as opioid deaths in Maine are on track to increase during the pandemic.

The policy change announced last week, in the final days of the Trump administration, will allow most physicians to prescribe the opioid medication buprenorphine. Health care providers previously needed to obtain a government waiver and undergo hours of training to be able to prescribe the medication.

Under the old policy, after undergoing the training and getting the license known as the X-waiver, physicians would be able to prescribe buprenorphine to up to 30 patients. The cap remains the same for the new version, but the training requirement to obtain a waiver has been removed.

Buprenorphine is a partial opioid agonist, which means it activates the opioid receptors in the brain and helps block the craving for drugs like oxycodone, heroin and fentanyl. But people on buprenorphine do not experience the same euphoria that can be caused by drugs such morphine or even methadone.

When buprenorphine is combined with naloxone, the overdose reversal medication, the product is called suboxone, which is frequently used in medication-assisted therapy for opioid use disorder.

National health leaders, including the American Medical Association, have long advocated for the removal of the waiver requirement to fight the stigma accompanying medication-assisted treatment of opioid use disorder. While the new policy expands the ability for physicians to prescribe buprenorphine, it is too early to tell what impact that will have on opioid addiction in Maine, according to Gordon Smith, who oversees the state’s opioid dependency reduction efforts.

Director of Opioid Response Gordon Smith speaks at a news conference in the State House, Wednesday, Feb. 6, 2019, in Augusta, Maine. Credit: Robert F. Bukaty / AP

From January to September 2020, 380 people died due to opioids, which is a 24 percent increase over the 306 drug-induced deaths from April to December of 2019. In a report released January 11, Drs. Marcella Sorg and Kiley Daley of the University of Maine’s Margaret Chase Smith Policy Center said the COVID-19 pandemic likely has increased the number of recent drug deaths in Maine, which mirrors increases in many other states.

“Many of us feel that [the training requirement] creates a mystique around the prescription of this drug that’s unjustified,” said Dr. Noah Nesin, Penobscot Community Health Care’s chief medical officer. “The nature of the training itself also creates an additional barrier because it makes the use of this drug seem more challenging than it actually is. Once people start treating people with buprenorphine, they realize that it’s not that complicated.”

The removal of these barriers is a good first step in order to treat more people with opioid use disorder with buprenorphine, according to Nesin and Smith. But currently, only 739 physicians, 304 nurse practitioners and 65 physicians’ assistants prescribe buprenorphine in Maine, according to Jackie Farwell, spokesperson for the Maine Department of Health and Human Services.

“Now the rubber will hit the road, and we’ll find out how many people really would prescribe it if they didn’t have to undergo that training,” Nesin said. “Or if that was just an excuse for not participating because of the stigma attached to this disease.”

The stigma attached to opioid use disorder is no different within the general public than it is within the medical community, Nesin said. Bangor health care providers including Northern Light Eastern Maine Medical Center and Penobscot Community Health Care have been working to address that internally.

“If we truly understand this as a chronic disease that’s treatable, like other chronic diseases, then we can dramatically reduce the mortality from this disease and none of us would resist treating people who have opioid use disorder,” Nesin said. “But because we view this, unfortunately and too often, as a character flaw instead of a disease model, there isn’t enough access to treatment.”

The removal of the waiver does not apply to nurse practitioners and physician assistants, who still have to undergo training and apply for a license to prescribe buprenorphine. Nurse practitioners and physician assistants have to undergo 24 total hours of training to get the waiver, while physicians only need 8 hours of training.

Nesin said the extended training requirement for nurse practitioners and physician assistants also acts as a barrier to buprenorphine access because the ones who undergo the training have been much more willing to prescribe buprenorphine, compared to other types of healthcare providers who have a lower training requirement.

Physicians wanting to prescribe the drug to more than 30 patients at a time still would have to receive the required training under the new policy, Nesin said.

“If everybody who was eligible participated, then you wouldn’t need that many physicians to treat more than 30 people,” he said. “If we make it a more normal part of primary care, more people will be doing it and that means access will be vastly improved.”

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