番茄社区

In this video, Jeremy Faust, MD, editor-in-chief of 番茄社区, sits down with Sarah Wakeman, MD, and Alister Martin, MD, to discuss the politics of opioid addiction treatment and the disparities built into the treatment system. This video is the second of two parts. Watch the first part, about the evolution of opioid addiction care, here.

Wakeman is the medical director for substance use disorder at Mass General Brigham (MGH) and an associate professor of medicine at Harvard Medical School in Boston.

Martin is faculty at the MGH Center for Social Justice and Health Equity at Harvard Medical School and founder of , a campaign aimed at transforming emergency departments nationwide into the front door for recovery for patients with opioid addiction.

The following is a transcript of their remarks:

Faust: Let's talk politics for just a second, because the [Drug Enforcement Administration (DEA)] X waiver has always been a political thing. It's a national policy.

There's always been concerns about two things that I think we've heard from people who maybe don't quite get it. One is that you're just replacing one opioid with another; you're just perpetuating the problem. The second one is that, now that the X waiver is gone, it's going to be even easier for people to use buprenorphine and divert it. In other words, not use it for the purposes of treatment, but actually for whatever abuse potential it may have, which doesn't seem to be a lot to me, but Alister, could you address those issues?

Martin: Yeah, I can certainly get us started on this.

The first thing that I'd say is that it depends on the question of do we think that this is a disease that, just like any other disease in medicine, requires and would benefit from treatment? In this case, what is the treatment? The treatment is evidence-based medication for addiction therapy, right?

At the end of the day, let's use an analogy to see if that does some work for folks on this. If you have diabetes, where do we start? We start with "Let's change your diet. Let's add some daily activity in the gym, lifestyle modification." If that does not work, what do we do? We don't say, "Well, gee, that didn't work. Why don't you keep trying that?" We start you on medication. And for many folks, starting on a medication like insulin is a lifelong thing, or metformin is a lifelong thing.

So when it comes to addiction treatment, for me as an individual provider, what I think a lot about is: is this treatment the right treatment for this patient? For many patients, that answer is yes, by getting them stabilized on buprenorphine. That does not mean it's best for everybody, but for many patients, it is the right way to go. So that's where I'll start.

Faust: What's the state of methadone these days? How does all this change for methadone, and how many patients are on methadone compared to buprenorphine? Those are the two main options for treatment. What's changed in terms of the law and in terms of people's interest in those options?

Wakeman: Yes, I mean, I think that's the next frontier. We've worked on buprenorphine, we now need to free methadone.

I think methadone regulations are archaic. They're mostly from the '70s under Nixon. We have this actually quite racist two-tiered system where buprenorphine is an office-based, more flexible option that, at least initially, was marketed mostly to commercially insured white people. There are huge racial disparities in access to buprenorphine.

Then you have methadone, where there's lots of studies -- like Dr. [Helena] Hansen in New York, and many other people have looked at this -- showing that methadone is more concentrated and more available in communities of color and much more restrictive.

So, you have to go every single day. You have to show up and get dosed often. Because of "not in my backyard" notions, methadone clinics, which are called opioid treatment programs, are located in areas of town that may already be dealing with poverty and other challenges.

Imagine: I'm a doctor, I'm a mom of three. Imagine if I had to go every morning someplace to get a medication just to stay well, to stay in recovery for my condition. It would be incredibly challenging. Methadone regulations are really tough.

I think we've seen during the time of COVID where there's much more flexibility actually. Patients were allowed to get take-home medications -- they could get 2 weeks of medication, for example, that they would take home like any other medication and take daily on their own.

That's how many other countries deal with methadone. Methadone is prescribed by doctors, and it's dispensed out of pharmacies. There isn't this methadone clinic model that we use in the United States.

I think that's the next thing we need to really push on is to modernize addiction treatment, to make this look like how we take care of any other health condition, and allow methadone to be dispensed at pharmacies and prescribed by physicians -- especially addiction treatment physicians.

Faust: You mentioned the pandemic, which I think is a really important part of this story. We all shut down, we went into our homes, and we hid for a couple of months. Then by the summer of 2020, people were back out and back to life.

My team saw this incredible, awful thing, which was that external death, death not caused by medical causes, suddenly skyrocketed by June and July of 2020, and it has been flat ever since -- unlike other forms of mortality, whether it's heart disease or cancer. Heart disease and cancer [mortality] goes with COVID, up and down and up and down together, but opioid and gun violence has just been flat and up since 2020, period.

I wonder why that is, but one thing I'm really, really worried about is whether or not people have access to these treatments via telehealth. So, what's the state of telehealth with getting started on opioid replacement therapy?

Wakeman: This is a hot topic because the public health emergency is slated to end on May 11th. With that, many of the flexibilities around prescribing controlled substances for pain and, for example, buprenorphine for opioid use disorder, would revert to pre-pandemic laws.

There's something called the Ryan Haight law, which makes it so you have to see someone in person before you can initiate them on a controlled substance. So telemedicine has allowed a lot of flexibility for people living with chronic pain, people living with lots of different chronic conditions that require controlled substances, and people with opioid use disorder who benefit from lifesaving therapy with buprenorphine.

I think the future is a little unknown -- in part because the DEA put forward proposals about 3 weeks ago -- they're open for public comment until March 31st -- proposing to allow some adaptations around initiating controlled substances via telemedicine but still requiring in-person visits within 30 days and other changes that I think many people are looking at closely and lots of folks are commenting on.

I think we are waiting to see what will happen with the DEA taking back the feedback that people are providing around these proposed changes. I think most of us hope that telemedicine will remain an option and in-person care will remain an option.

People need lots of different ways to access care, especially for mental health or substance use disorder or for pain. These are conditions that we don't have enough providers that can treat them across the country. That's really true in rural areas where people are sometimes driving hundreds of miles or across state lines to see a provider.

Martin: Real quickly on that, please, Jeremy. I think Sarah nailed it. The other thing to consider and to keep in the back of our minds, though, is that in this country, internet access is not widely distributed or fairly distributed, right? There's still 20% of the population that does not even have high-speed internet at home. When you then break that out into low-income communities and the elderly, those numbers go up.

So really making sure that, first, we do need to keep those telehealth provisions in place, and simultaneously, we need to "walk and chew gum" at the same time -- make sure that we get people access to things like telehealth, like broadband, like high-speed internet.

Otherwise, we are just going to further widen the disparity in terms of who can get access to these medications and who cannot.

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