In this video, Jeremy Faust, MD, Editor-in-Chief MedPage Today, sits down with Sarah Wakeman, MD, and Alistair Martin, MD, to discuss opioid addiction treatment policies and inconsistencies built into the treatment system. This video is the second of two parts. See the first part on the evolution of opioid addiction treatment here.

Wakeman is Medical Director of Substance Use Disorders at Mass General Brigham (MGH) and Associate Professor of Medicine at Harvard Medical School in Boston.

Martin is a faculty member at the Center for Social and Health Equity at MGH Harvard Medical School and founder Get rejecteda campaign to turn emergency rooms across the country into the front door to the recovery of patients with opioid dependence.

Below is a transcript of their speech:

Fist: Let’s talk about politics for a second, because [Drug Enforcement Administration (DEA)] X refusal has always been a political matter. This is national policy.

There have always been concerns about two things that I think we’ve heard from people who may not quite understand it. First, you are simply substituting one opioid for another; you’re just making the problem worse. The second is that now that there is no more withdrawal from X, it will be even easier for people to use buprenorphine and distract him. In other words, using him not for healing purposes, but actually for the potential abuse he might have, which doesn’t sound like much to me, but Alistair, can you address these issues?

Martin: Yes, I can definitely start with that.

The first thing I would like to say is that it depends on the question: do we think that this is a disease that, like any other disease in medicine, requires treatment and will benefit? In this case, what is the treatment? Treatment is based on evidence-based medicine for addiction treatment, right?

In the end, let’s use an analogy to see if this helps people with this. If you have diabetes, where do you start? We start with “Let’s change your diet. Let’s add daily activity in the gym, change the way of life.” If this doesn’t work, what should we do? We don’t say, “Gee, it didn’t work. Why don’t you try again?” We’ll start you on medication. And for many people, starting medications like insulin or metformin is lifelong.

So when it comes to addiction treatment, as an individual provider I think a lot about whether this treatment is right for this patient? For many patients, the answer is yes when stabilized with buprenorphine. This does not mean that it is best for everyone, but for many patients this is the right way to go. Here’s where I’ll start.

Fist: What is the status of methadone these days? How does all this change for methadone, and how many patients are taking methadone compared to buprenorphine? These are the two main treatment options. What has changed in terms of the law and in terms of people’s interest in these options?

Wakeman: Yes, I mean, I think this is the next frontier. We’ve been working on buprenorphine, now we need to release methadone.

I think the methadone rules are archaic. They are mostly from the 70s under Nixon. We actually have a rather racist two-tier system where buprenorphine is a more flexible option for the office, which, at least initially, was sold mostly to white people with commercial insurance. There are huge racial disparities in access to buprenorphine.

Then you have methadone, which has a lot of research on it, like Dr. [Helena] Hansen in New York and many others have observed this, showing that methadone is more concentrated and more accessible to communities of color and much more strict.

So you have to walk every day. You must show up and dose frequently. Because of the notion of “not in my backyard,” methadone clinics, called opioid treatment programs, are located in areas of the city that may already be struggling with poverty and other problems.

Imagine: I am a doctor, I am a mother of three children. Imagine if I had to go somewhere every morning to get my medicine, just to stay healthy, to recover from my condition. It would be incredibly difficult. The rules for methadone are really tough.

I think we saw in the days of COVID when there was actually a lot more flexibility. Patients were allowed to take medications at home – for example, they could receive medications for 2 weeks, which they took home, like any other medications, and took daily on their own.

This is how many other countries deal with methadone. Methadone is prescribed by doctors and sold in pharmacies. There is no methadone clinic model that we use in the United States.

I think the next thing we really need to do is modernize addiction treatment to look like we care about any other health condition and allow methadone to be sold in pharmacies and prescribed by doctors – especially addiction treatment. doctors.

Fist: You mentioned the pandemic, which I think is a really important part of this story. We all closed down, we went home and hid for a couple of months. Then by the summer of 2020, people returned to life.

My team saw this incredible, horrifying thing, which was that external death, death not caused by medical causes, suddenly skyrocketed by June and July 2020, and it has remained the same ever since – unlike other forms of mortality. be it heart disease. or cancer. Cardiovascular disease and cancer [mortality] goes with COVID, up and down, up and down together, but opioid and gun violence has remained the same since 2020, period.

I wonder why that is, but one thing that I’m very, very worried about is whether people have access to these therapies through telehealth. So what is the state of telehealth with the start of opioid substitution therapy?

Wakeman: This is a hot topic because the public health emergency is due to end on May 11th. In doing so, many of the flexibilities regarding the prescription of controlled substances for pain and, for example, buprenorphine for opioid use disorders, will revert to pre-pandemic laws.

There’s something called Ryan Haight’s law that says you need to see someone in person before you can initiate them on a controlled substance. Thus, telemedicine has provided greater flexibility for people living with chronic pain, people living with many different chronic conditions requiring controlled substances, and people with opioid use disorder who are helped by buprenorphine-saving therapy.

I think the future is a bit of an unknown – partly because the DEA put forward proposals about 3 weeks ago – they’re open for public comment until March 31st – suggesting to allow some changes regarding initiation of controlled substances via telemedicine, but still requiring in-person visits during 30 days and other changes that I think a lot of people are looking into and a lot of people are commenting on.

I think we’re waiting to see what happens with the DEA taking the feedback that people provide on these proposed changes. I think most of us are hoping that telemedicine will remain an option and in-person care will remain an option.

People need many different ways to access health care, especially for mental health, substance use disorders, or pain. These are conditions where we don’t have enough providers who can treat them all over the country. This is indeed true in rural areas where people sometimes drive hundreds of miles or cross state lines to see a service provider.

Martin: Very quickly, please, Jeremy. I think Sarah did well. Another thing to consider and remember is that in this country internet access is not widespread or fair, right? Until now, 20% of the population does not even have high-speed Internet at home. When you then break that down into low-income communities and older people, those numbers go up.

So, really making sure that, first of all, we need to keep these provisions of telemedicine, and at the same time, we need to “walk and chew gum” at the same time – make sure that we provide people with access to things like telemedicine, like broadband access. like high speed internet.

Otherwise, we will only deepen the disparity in who can and cannot access these medicines.