I am a physician who specializes in the treatment of addiction and my patients are dying. Among them, a sweet legally blind kid with thick glasses, barely in his twenties, who used heroin and then fentanyl. He needed treatment with methadone, but federal regulations intentionally limit access to that lifesaving medication. So, he died instead. Another patient: a sixty-year-old woman hooked on pain pills. I started her on a medication called buprenorphine that has an excellent track record of treating opioid addiction. She stopped using drugs and moved to rural Oregon to reunite with her children. But near her new home, there was only one doctor who would agree to continue her prescription, and when he retired, she lost access to the medication. She started using again. And then she died.
Yes, my patients chose to take the drugs that eventually killed them, but before they died, they also tried to take evidence-based medications that could help them stop. Unfortunately, they discovered it is much, much easier in this country to find a fentanyl dealer than to find a way through the multiple, unconscionable barriers limiting access to these essential medications.
Methadone and buprenorphine are opioids themselves. Unlike other opioids, however, methadone and buprenorphine save lives. They decrease cravings, decrease use, and decrease deaths. Methadone is what is known as a “full agonist” at the opioid receptor, which means it sits on the receptor and activates it fully, just like morphine, oxycodone, or fentanyl. The difference with methadone is that it builds up slowly and sticks around, so there are no rapid highs and few deep dives into withdrawal. At the right dose, it activates the receptor just enough to remove cravings and stem withdrawal, helping patients focus on other, valued parts of their lives.
Buprenorphine is a “partial agonist,” meaning it occupies the opioid receptors but only partially activates them, decreasing cravings and withdrawal without an accompanying high. Because it is a partial agonist, it is very difficult for anyone to overdose on buprenorphine. It doesn’t have the potency necessary for complete respiratory depression. Also, because it binds the receptors tightly, it keeps other opioids from binding on the receptor, which means that when it is in a person’s system, it protects that person from overdosing on any other opioids as well.
Both are excellent medications, but methadone is stronger than buprenorphine. For users of fentanyl, it is sometimes the only medication strong enough to stem cravings. However, federal rules can make it near impossible for some patients to access methadone to treat their addiction. The rules stipulate that patients may only obtain methadone from an opioid treatment program (OTP), and, for the first three months of treatment, they must attend the OTP in person daily to receive their medication. They receive just one dose a day. It doesn’t matter if the OTP is hundreds of miles from their home, if a job or childcare makes it impossible to pick up the medication on time, or if they have no car to get there.
Furthermore, rules stipulate that the initial dose must be no higher than thirty milligrams, which generally doesn’t come close to curbing cravings. With this insufficient dose, patients often keep using opioids on top of methadone. When they test positive, they don’t earn take-home doses, which means that they remain shackled to the OTP, sometimes waiting in long lines, sometimes in cold, wet parking lots, sometimes in terrible heat. It is almost as if the regulations were specifically designed to be shaming.
When buprenorphine was approved by the Food and Drug Administration (FDA) in 2002, it was an intense relief to physicians like me to know that we could offer a treatment for opioid addiction that did not require daily attendance at an OTP. Buprenorphine could be prescribed by a regular doctor in a regular clinic. Still, initial regulations limited who could prescribe it (only providers with a special federal waiver) and to how many patients (thirty at a time).
Faced with a tidal wave of fentanyl-related sickness and death, Congress has whittled away at the rules surrounding buprenorphine until, recently, nearly all barriers to prescribing it were removed. Unfortunately, however, most medical providers still don’t prescribe the medication. It was too long considered outside the scope of regular care, and the tight prescribing limits made it seem as if the medication, and the patients who needed it, were too complicated, perhaps even dangerous. Best to avoid, too many physicians concluded.
Similarly, most pharmacies don’t stock the medication, and some won’t fill the prescriptions at all. Distributors also cap the quantity of buprenorphine an individual pharmacy can dispense. I am lucky. I work in a city. When Target won’t dispense, we call CVS, then Rite Aid, then Costco, until we find a pharmacy that has the medication. Patients in rural areas aren’t so fortunate. If the pharmacy doesn’t have it, they go without. Many likely begin using again. Some of them likely die.
Last month my sister was prescribed a bottle of fifteen oxycodone pills after a minor outpatient procedure, even though she said she didn’t want the drug; she didn’t even need Tylenol afterwards. She could have picked up the meds, no problem, at the corner pharmacy. But had she wanted a medication to quit taking pills or heroin or fentanyl? If she asked for help with that, would she have found one of the minority of providers in the United States who prescribe buprenorphine and then found a pharmacy to fill the prescription? Or would she have been willing to stand in that methadone line, every morning, while her kids were at home, while she worried about making it to work on time, while she hoped no one she knew would see her?
There is widespread sentiment I have heard at least a hundred times: people who take buprenorphine or methadone are just “replacing one addiction with another.”
Addiction is defined as the compulsive use of drugs or alcohol in a manner that makes the user’s life worse. It is use that leads you to skip your daughter’s basketball game because you are sick with withdrawal. It is a weekend of oxycodone that leads to missing work on Monday, again. It is knowing you might die but injecting fentanyl anyway. When my patients stabilize on buprenorphine or methadone, they start going to the basketball games, stay employed, stop injecting, don’t overdose. They don’t die.
It is true that both buprenorphine and methadone can be misused or diverted and sold. I’m not arguing that the medications should be handed out willy-nilly. But they should be prescribed in the same way we prescribe other potent, lifesaving medications: with close attention to benefits and harms, with the expectation that our prescriptions will be filled, and without stigma, shaming, or life-jeopardizing restrictions.
In some minor good news, the Department of Health and Human Services is considering an update to the methadone rules, adding a drib of telehealth here and drab of dosing flexibility there. But there is no proposal for real change. Tinkering around the edges is not enough. We need to dismantle the disgraceful rules surrounding provision of methadone, incentivize buprenorphine prescriptions, and require pharmacies to stock these lifesaving medications.
Until then, if, for instance, you are a blind kid, barely twenty years old, shooting fentanyl, with no reliable means of transportation and no family around to help, you might give up on trying to get to the methadone clinic after a few weeks of missed buses, missed appointments, missed doses. You might know that you need the medication, but you also know that this is not a life you can lead.
So, in the end, you lead no life at all.