Problem

Stigma is a major barrier to increasing participation in treatment for substance use disorder. Three-quarters of healthcare providers surveyed describe stigma towards patients with opioid use disorder as a reason that more healthcare providers do not prescribe buprenorphine.

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Sonia Mendoza, et al., Shifting blame: Buprenorphine prescribers, addiction treatment, and prescription monitoring in middle-class America, 53(4) Transcult Psychiatry 465-87 (2016) (“Overall, 75% of physician participants identified negative attitudes towards substance abuse patients or addiction treatment as dissuading doctors from prescribing buprenorphine.”); Nat’l Acad. of Sciences, Engineering, and Medicine (“NASEM”), Consensus Study Report: Medications for Opioid Use Disorder Save Lives, Nat’l Acad. Press, at 16 (2019) https://bit.ly/3rcr3sA (“The stigmatization of people with OUD is a major barrier to treatment seeking and retention…Patients with OUD also report stigmatizing attitudes from some professionals within and beyond the health sector, further undercutting access to evidence-based treatment. The medications, particularly the agonist medications, used to treat OUD are also stigmatized. This can manifest in providers’ unwillingness to prescribe medications due to concerns about misuse and diversion and in the public’s mistaken belief that taking medication is ‘just substituting one drug for another.’”).

The federal restrictions on prescribing buprenorphine for opioid use disorder foster this stigma by singling out patients with opioid use disorder and medications for the condition.

The federal restrictions isolate patients with substance use disorder. To treat patients with a safe medication that has been FDA approved since 1981, medical providers must overcome bureaucratic and onerous barriers that do not exist for any other medical condition. Medical providers must limit the number of patients with opioid use disorder they can treat, file special registrations with SAMHSA and the DEA, and mark their prescriptions with a special identifier that discloses the patient’s substance use disorder. No other medical condition is subject to these restrictions.

²

Christine Vestal, “Waiting Lists Grow for Medicine to Fight Opioid Addiction,” The Pew Charitable Trusts (Feb. 11, 2016), https://bit.ly/31dXQCQ (“No other medication requires a special license, and no other disease is subject to a patient limit, argued Dr. Kelly J. Clark, president-elect of the American Society of Addiction Medicine.”).

The difference in how federal law treats patients in pain compared to patients with substance use disorder fosters stigma and imposes barriers to treatment. Medical providers can prescribe buprenorphine to a person in pain without additional training.

³

Kevin Fiscella, MD, MPH, Sarah E. Wakeman, MD, Leo Beletsky, JD, MPH, Buprenorphine Deregulation and Mainstreaming Treatment for Opioid Use Disorder: X the X Waiver, 76(3) JAMA Psychiatry 229-30 (2018), https://bit.ly/2QD4II3 (“Buprenorphine’s X-waiver only applies when it is prescribed to treat OUD, but not for pain. Ironically, a comparatively safer medication that is critical to reducing deaths from the opioid epidemic is regulated more tightly than medications largely responsible for creating the epidemic. “)

But to prescribe the exact same medication to a person with substance use disorder, they must undertake the above onerous requirements. The federal barriers lead many medical providers to believe that treating patients with subtance use disorder is difficult, when in fact substance use disorder is as treatable as other chronic medical conditions like diabetes.

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Nat’l Acad. of Sciences, Engineering, and Medicine (“NASEM”), Consensus Study Report: Medications for Opioid Use Disorder Save Lives, Nat’l Acad. Press, at 16 (2019) https://bit.ly/3rcr3sA (“The stigmatization of people with OUD is a major barrier to treatment seeking and retention…Patients with OUD also report stigmatizing attitudes from some professionals within and beyond the health sector, further undercutting access to evidence-based treatment. The medications, particularly the agonist medications, used to treat OUD are also stigmatized. This can manifest in providers’ unwillingness to prescribe medications due to concerns about misuse and diversion and in the public’s mistaken belief that taking medication is ‘just substituting one drug for another.’”); Kevin Fiscella, MD, MPH, Sarah E. Wakeman, MD, Leo Beletsky, JD, MPH, Buprenorphine Deregulation and Mainstreaming Treatment for Opioid Use Disorder: X the X Waiver, 76(3) JAMA Psychiatry 229-30 (2018), https://bit.ly/2QD4II3 (“(“Regulations reinforce the stigma surrounding buprenorphine prescribers and patients who receive it while constraining access and discouraging patient engagement and retention in treatment. This marginalization created by X-waivers undermines the principle that OUD is a chronic condition that is similar to other chronic medical or mental health conditions that are managed by primary care clinicians.”).

As the American Medical Association has noted, “[i]nstead of helping to eliminate stigma, the waiver requirements may reinforce and amplify it because they place people with [opioid use disorder], medications to treat [opioid use disorder], and physicians who provide [medication-assisted treatment] into a special DEA category."

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Letter from American Medical Assoc. (“AMA”) to Sec. Alex Azar (Jun. 2, 2019), https://bit.ly/3lKsnBM.

Patients with opioid use disorder are just like other patients - they are teachers, nurses, policemen, and CEOs who deserve healthcare.

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Sonia Mendoza, et al., Shifting blame: Buprenorphine prescribers, addiction treatment, and prescription monitoring in middle-class America, 53(4) Transcult Psychiatry 465-87 (2016). ("A majority of the community-based private practitioners reported that most of their patients were from within their neighborhood and did not fit the stereotype of “user.” For example, one prescriber asserted that people who came to his clinic for buprenorphine maintenance were “not criminals; they’re teachers, nurses, policemen, CEOs.” Despite this, prescribers also expressed that other physicians were hesitant about becoming certified or providing buprenorphine maintenance treatment because of the stigmatized nature of the opioid dependent patient.”).

But current federal law isolates these patients and fosters misconceptions and stigma.

Solution

The Mainstreaming Addiction Treatment Act will help eliminate stigma towards people with opioid use disorder by integrating substance use disorder treatment into the healthcare system.

The bill will allow all medical providers with a standard controlled medication license to prescribe buprenorphine for opioid use disorder just as they prescribe medications for other chronic conditions. Primary care providers can screen for substance use disorder, discuss treatment options, and prescribe a safe, effective medication to help their patients achieve long-term recovery.

According to the National Academy of Sciences, Engineering and Medicine, primary care clinics that integrate substance use disorder treatment into their services report less stigma.

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Nat’l Acad. of Sciences, Engineering, and Medicine (“NASEM”), Consensus Study Report: Opportunities to Improve Opioid Use Disorder and Infectious Disease Services, Nat’l Acad. Press at 81-81 (2020), https://bit.ly/3fnzdMD (“Provider stigma toward individuals with OUD has been noted in the literature as a problem that can hinder care delivery and quality. Primary care clinics, in particular, reported that integrating OUD treatment within primary care services resulted in less stigmatization. One reason is that, in an integrated clinic, patients may be visiting for any number of reasons, including SUD or infectious diseases or simply a primary care checkup.”).

The Mainstreaming Addiction Treatment Act will help eliminate stigma by treating substance use disorder the same as other chronic medical conditions.