Problem

Healthcare providers routinely learn how to treat new conditions. COVID-19 has shown how healthcare providers incorporate ongoing education into their medical practices so they can ensure that their patients receive up-to-date, quality care.

But the federal government prohibits healthcare providers from learning how to treat opioid use disorder as they do other conditions. Under federal law, healthcare providers who treat more than 30 patients at a time with buprenorphine must complete 8-24 hours of training on the medication.

These training protocols impose barriers to patients accessing lifesaving treatment. The National Academy of Sciences, Engineering, and Medicine has noted that “the waiver training itself is clinically irrelevant to [medical providers’] day-to-day practice.”

¹

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 56 (2020), https://bit.ly/2PoASq2.

Nearly 7 in 10 physicians surveyed state that the 8-hour federally mandated training course discourages physicians from prescribing buprenorphine to patients with opioid use disorder.

²

Sonia Mendoza, et al., Shifting blame: Buprenorphine prescribers, addiction treatment, and prescription monitoring in middle-class America, 53(4) Transcult Psychiatry 465-87 (2016), https://bit.ly/3snbiPS.

Even when the course is free and continuing medical education credits are offered, healthcare providers do not sign up for the trainings.

³

See Adam J. Gordon, M.D., M.P.H., et al., Outcomes of DATA 2000 Certification Trainings for the Provision of Buprenorphine Treatment in the Veterans Health Administration, 17 Am. J. on Addictions 459-62 (2008).

The federal training requirement does not align with how healthcare providers learn and restricts the number of healthcare providers who can prescribe buprenorphine for opioid use disorder.

In addition, the federal training requirement stigmatizes patients with 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.’”).

Medical providers can prescribe buprenorphine to a person in pain without additional training.

⁵

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 substance use disorder is difficult, when in fact substance use disorder is as treatable as other chronic medical conditions like diabetes.

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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.”).

The federal training requirement fosters this stigma by singling out patients with opioid use disorder.

For these reasons, the National Academy of Sciences, Engineering, and Medicine has called for Congress to remove the training requirement.

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National Academy of Sciences, Engineering, and Medicine, Consensus Study Report: Opportunities to Improve Opioid Use Disorder and Infectious Disease Services, Nat’l Acad. Press (2020) ("Congress should amend Section 303 of the Controlled Substances Act to allow buprenorphine and other medications for opioid use disorder to be prescribed by physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, or certified nurse midwives without undergoing the mandatory training currently required by law, requiring a Drug Addiction Treatment Act waiver, or limiting the number of patients that can be treated.").

Instead of federally mandated one- to three-day trainings, medical providers report that mentorship and continuing medical education courses would increase their likelihood of prescribing buprenorphine for opioid use disorder.

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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 121 (2019) https://bit.ly/3rcr3sA (“In a survey of non-waivered providers, respondents indicated a number of factors that could increase their willingness to begin prescribing buprenorphine, including being provided with information about local counseling resources, having access to an experienced prescriber for consultation, and receiving continuing medical education about OUD.”).

For current healthcare providers, those training and mentorship resources are currently available through standard education programs, including from the American Medical Association, state centers of excellence, Providers Clinical Support System, and Project ECHO. More than 700,000 medical providers access continuing education through the American Medical Association and state and medical specialty societies every year.

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Letter from American Medical Assoc. (“AMA”) to Sec. Alex Azar (Jun. 2, 2019), https://bit.ly/3vTa5CZ (“In 2015, the AMA made a commitment along with many of our partners in the state and specialty medical societies to help increase the number of physicians who become educated on OUD treatment, safe opioid prescribing, pain management, and similar topics. Hundreds of these courses are accessible through the AMA-maintained website at https://www.end-opioid-epidemic.org/ and the AMA educational site at https://edhub.ama-assn.org/pages/opioid-cme-course. In 2018, more than 700,000 physicians and other health professionals accessed continuing medical education and other training resources provided by the AMA and state and medical specialty societies.”); see e.g., Rutgers Northern New Jersey MAT Center of Excellence, https://bit.ly/3d8V8Ey; Pennsylvania Centers of Excellence for Opioid Use Disorder, https://bit.ly/3fajm3H; ECHO Institute, Medication Assisted Treatment, https://bit.ly/3d8Vb3c (offering weekly free education and mentorship programs on medication assisted treatment for opioid use disorder).

In addition, graduate schools can expand training on providing medications for opioid use disorder. While only 1 in 191 medical schools provide the full 8-hour federally-mandated training to prescribe buprenorphine for opioid use disorder, nearly 9 of 10 medical schools provide curricula on how to identify and treat substance use disorder.

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AAMC, Addressing the Opioid Epidemic: U.S. Medical School Curricular Approaches, at 1 Figure 1: Percentage of U.S. medical schools reporting number of pain and substance use disorder domains addressed in their curricula (2018), https://bit.ly/3f7sCFP (showing 87% of medical schools surveyed include all pain and substance use disorder domains in their curricula); Melissa B. Weimer, DO, MCR, Sarah E. Wakeman, MD and Richard Saitz MD, MPH, Removing One Barrier to Opioid Use Disorder Treatment: Is It Enough?, JAMA (Feb. 25, 2021) https://doi:10.1001/jama.2021.0958 (“As of 2018, only 1 of 191 medical schools provided training to their students that was sufficient to meet the DATA 2000 training requirement.”).

Graduate schools can build on the training they provide to further encourage new healthcare providers to treat patients with substance use disorder.

Effective, high-quality education for healthcare providers on how to treat patients with substance use disorder already exists, but the current federal training requirement discourages healthcare providers from treating substance use disorder.

Solution

The Mainstreaming Addiction Treatment Act expands access to effective education on substance use disorder. The bill removes the current ineffective training requirement. In its place, the Mainstreaming Addiction Treatment Act launches a national education campaign to connect medical providers to publicly available training resources on best practices for treating opioid use disorder.