There have been scant opportunities for optimism in the past year. COVID-19 has taken so much from us – our loved ones, our economic security, our sense of community. One positive in the midst of this chaos came in the form of an underreported policy change from HHS. On January 14, Admiral Brett Giroir of HHS around prescribers' ability to provide medication-assisted treatment (MAT) for opioid use disorder (OUD). Specifically, the new rule removed the need for providers to obtain an "X-waiver" from the Drug Enforcement Administration (DEA) to prescribe buprenorphine.
The X-waiver represents an enormous barrier to effectively addressing the nation's opioid use emergency. With from opioid overdoses from June 2019 to June 2020 alone, the crisis represents a huge public health challenge. COVID-19 has only exacerbated this situation, with increases in , , and . As people deal with the overlapping traumas of social isolation, loss of loved ones, and loss of livelihood, typical coping mechanisms may not be available or adequate. Rates of opioid use and associated overdose may continue to rise as the long-lasting impacts of the pandemic become clear.
Medication-assisted treatment is a key strategy in addressing these overlapping crises. Harm reductionists have long recognized the value of this form of treatment offered in conjunction with behavioral and social interventions. A of the use of buprenorphine in the treatment of OUD concluded the drug is effective in treatment of heroin dependence and suppressing illicit opioid use. This amalgamation of placebo-controlled trials provides some of the strongest evidence available in medicine of the benefits of this critical drug. Similarly, a retention in MAT was associated with substantial reductions in both all-cause and overdose mortality.
Despite this overwhelming, high-quality evidence of the efficacy of MAT and its potential to bend the curve on OUD-related mortality, a number of barriers to widespread uptake remain. Principally, the X-waiver requires additional training and an application to the DEA. The process is administratively laborious, with input needed from the DEA, Substance Abuse and Mental Health Services Administration, and Department of Justice. In addition, the regulations a physician can treat with MAT to 30 individuals. The additional training requirement is an anathema in medicine, in which a physician is generally entitled to full prescribing privileges after completing a one-year internship and passing the relevant board examination.
Physicians who practice in areas ravaged by OUD and overdose deaths as well as harm reductionists, therapists, and treatment centers were ecstatic about the relaxation of restrictions. As a result, with the recent news that the Biden administration is back-tracking on the policy change, these groups were understandably frustrated. Explaining that the announcement was made prematurely, the that would have ultimately done away with the outdated, onerous regulation. This despite the fact that leading medical professionals and physician groups have been calling for its rescinding for years.
It is counterintuitive that the new administration, touting its comprehensive commitment to arresting the death and destruction from the COVID-19 pandemic, would shy from fully addressing this syndemic. With a stroke of his pen on inauguration day, President Biden enacted executive orders mandating masking on federal property and in interstate commerce, a move will assuredly save numerous lives; with a similar action, the president could unshackle the hands of the entire primary care physician workforce to heal a hurting nation.
Members of Congress have just , the Mainstreaming Addiction Treatment (MAT) Act, to address this issue. Senators Maggie Hassan (D-N.H.) and Lisa Murkowski (R-Alaska) are leading the charge in the upper chamber, while Rep. Paul Tonko (D-N.Y.) has previously introduced sibling legislation in the House. However, given the political burden of wrangling 538 competing interests in the legislative branch, swift action from the executive is preferable at this point. And based on the administration's commitment to setting evidence-based policy, the correct path seems obvious.
We can raise our voices as physicians to right this wrong, advocate for rapid federal action, and set the nation on a new path. It is the least we can do.
Keanan McGonigle, MD, MPP, is a PGY-1 in internal medicine at George Washington University; he graduated from Tulane University School of Medicine and spent a year working in public policy and medical student advocacy before starting residency. He plans to go into primary care and has particular interests in geriatrics and HIV medicine.