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Spread the word: You don't need to die from an opioid overdose!

Drug overdose, principally due to opioids, is rising in many developed countries; in the United States, drug overdose has been the leading cause of injury-related death since 2009, with opioid overdose alone the leading cause since 2016. In the United States, the number of opioid-involved overdose deaths more than doubled, from 25,052 to 50,178 between 2013 and 2020. The rise in lethal opioid overdoses has been seen with prescription opioids, heroin, and synthetic opioids. Synthetic opioids, namely Fentanyl, are responsible for most opioid overdoses (73 percent of opioid overdose deaths in 2020). This rise has been driven by illicitly manufactured fentanyl. Fentanyl is increasingly present in other street drugs, including cocaine, methamphetamine, and counterfeit pills, and is believed to be related to increased rates of overdose death involving those substances as well.

Clearly what we do in the United States to prevent accidental overdose deaths has not worked. The current community based intervention program for opioid overdose prevention involves education and provision of take-home naloxone to patients at risk of an overdose, their caregivers, and household members. Broad access to naloxone has been recommended by the United States surgeon general. Programs that provide sterile syringes and safe disposal equipment to high-risk populations are well positioned to educate their clients about opioid overdose and offer naloxone to reverse overdoses. As of 2019, 94 percent of syringe access programs in the United States had initiated naloxone distribution programming. Participants are taught to recognize risk factors for overdose, signs and symptoms of overdose, and how to administer naloxone.

However, there has been a medicine available called buprenorphine which would save thousands of lives if given to patients with an opioid use disorder. The problem is that the Drug Enforcement Agency (DEA) has made it nearly impossible to get. But in Mexico, you can get it over-the-counter at a pharmacy. The DEA’s position on buprenorphine is reprehensible. The use of buprenorphine has been limited to waivered clinicians registered with the United States Center for Substance Abuse Treatment and the Drug Enforcement Administration and may be given in an office setting. The number of waivered clinicians are “few and far between”. Just 5% of medical providers have been licensed to prescribe buprenorphine, and in large portions of the country there are no physicians licensed to prescribe it. The Drug Enforcement Agency required clinicians who wanted to prescribe buprenorphine for the treatment of opioid use disorder to undergo an extensive training and registration process for the “X-waiver,” so named because, upon completion, an “X” was added to the clinician’s DEA registration number. This time-consuming process erected a barrier that discouraged doctors from prescribing buprenorphine for opioid use disorder. The waiver also contributed to the ongoing stigma around both opioid use disorder and buprenorphine, because while any physician can prescribe buprenorphine for chronic pain without a special waiver, the specter of “abusers” who might sell or in some way misuse this pharmaceutical meant that only specially trained experts could be trusted to prescribe buprenorphine for opioid use disorder. So many have died needlessly, yet the government has been unwilling to budge to make it easier for clinicians to prescibe until now.

Included in the end-of-year appropriations bill that President Biden signed on December 29, 2022 was the bipartisan Mainstreaming Addiction Treatment (MAT) Act of 2023. This act eliminates the so-called X-waiver that physicians had long needed to prescribe buprenorphine, a medication that curbs opioid cravings, reduces drug use, and prevents deaths among people who use opioids. In the United States, only 27% of people who would benefit from taking medication to treat opioid use disorder are currently on treatment. Every study of buprenorphine shows it prevents death, decreases the time people use opioids, and reduces crime. The X-waiver represented a massive barrier to the treatment and care for people with opioid use disorder. Eliminating it will expand access to treatment for opioid use disorder, provide additional resources to first responders, and direct the federal government to raise public awareness on the potency and dangers of fentanyl and other synthetic opioids.

The MAT Act’s potential to truly bend the curve of overdose death has not been matched by its roll-out. The appropriate agencies made their announcements, and addiction-focused advocacy groups have tried to amplify the message. But there is no major effort to reach beyond the small pool of existing addiction medicine and psychiatry providers who are already prescribing buprenorphine, nor is there a clear plan to support providers to expand the scope of their practices. Further, the MAT Act does nothing to dismantle varying state-level regulations that also erect barriers to treatment. Vigorously communicating the MAT Act’s historic changes and investing in ancillary supports that prescribers need to effectively manage patients on buprenorphine would increase the number of providers who prescribe this medication, which in turn would reduce fatal drug overdoses. In France, removing regulations limiting buprenorphine prescribing was followed by a 79% decrease in deaths from opioid overdoses over the next three years. Extrapolated to the United States, that would translate to more than 30,000 fewer deaths each year from opioid overdoses.

The MAT Act will let health care providers prescribe buprenorphine as they would any other medicine, which may help normalize its essential role in treating opioid use disorder. Although the act does direct the Substance Abuse and Mental Health Services Administration to conduct national awareness campaigns that encourage providers to incorporate medication treatment and addiction services into their practices, there has been little action and few plans beyond that high-level commitment. Communicating major public health milestones is a prerequisite to seeing changes in public health. Local media, national media, advocacy organizations, departments of health, and medical and scientific societies should be working in concert now to raise awareness about better access to buprenorphine. People with opioid use disorder need to know they can now ask their current health care providers for buprenorphine treatment — and gently educate them, if needed, that an X-waiver is no longer required to provide that.

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