Jeffrey A. Singer
Last March, I wrote about a recent episode of “Cops Practicing Medicine,” in which the Drug Enforcement Administration inserted itself into the medical management of opioid use disorder by proposing telehealth guidelines that undermined Congress’ intentions when it passed the Mainstreaming Addiction Treatment (MAT) Act at the end of 2022. The act removed the onerous rules and regulations surrounding the “X waiver” that the DEA required health care practitioners to obtain if they wanted to treat addiction with buprenorphine. The DEA’s proposed rule requires that any patients initially begun on buprenorphine via telehealth must see the prescribing practitioner in person within 30 days. The rule limits the prescription to a 30‐day supply. The cops are concerned that patients will “abuse” or “divert” the buprenorphine into the black market if they do not get personally inspected by the physician after 30 days. The DEA has delayed implementing the proposed rule until the end of next year.
Doctors who treat substance use disorder begged to differ from the cops and offered a second medical opinion.
Addiction specialists are concerned that the proposed rule will reduce access to buprenorphine treatment and will undermine lawmakers’ intent to make it easier for people to get treatment for opioid use disorder. Dr. Brian Hurley, president‐elect of the American Society of Addiction Medicine, told STAT News, “I don’t want federal rules dictating to me when I have to cut somebody off a medication that, on the basis of the information available to me, is still appropriate for the patient.”
It already averages 26 days to get a new appointment with a primary care provider, so there is no guarantee a new buprenorphine patient can get an appointment within the 30‐day window. It might be even more difficult in rural or other areas with primary care provider shortages. The proposed DEA rule is likely to abruptly cease treatment for many patients who have just begun treatment using telehealth. Shortened or abrupt cessation of treatment will very likely cause patients to resume non‐medical use of opioids in the dangerous black market.
Now, a bipartisan group of US senators has decided to go with the second opinion. Senators Sheldon Whitehouse (D‑RI), Lisa Murkowski (R‑AK), Marsha Blackburn (R‑TN), and Mark Warner (D‑VA) have introduced the Telehealth Response for E‑prescribing Addiction Therapy Services (TREATS) Act. The bill would allow providers to waive the in‐person requirement. The senators argue that, in 2020, the DEA and the Substance Abuse and Mental Health Services Administration allowed patients to receive buprenorphine via telemedicine without requiring them to see clinicians in person as an emergency measure during the COVID-19 pandemic, and there is no evidence that patients abused or sold the medication on the black market.
Buprenorphine is a weak partial opioid agonist, unpopular among recreational drug users. Studies indicate that most people who buy buprenorphine on the street are self‐administering medication‐assisted treatment with buprenorphine because they can’t get appointments for treatment.
A shortcoming of the TREATS Act is that it doesn’t overrule the cops’ 30‐day supply rule. Clinicians, not cops, should decide how much buprenorphine to prescribe based on their judgment and knowledge of their individual patient’s circumstances.
Senators Catherine Cortez Masto (D‑NV), Thom Tillis (R‑NC), Tim Kaine (D‑VA), Shelley Moore Capito (R‑WV), Amy Klobuchar (D‑MN), Mark Kelly (D‑AZ), and Cory Booker (D‑NJ have joined the bill as co‐sponsors. Representatives David Trone (D‑MD), Jay Obernolte (R‑CA), and Brian Fitzpatrick (R‑PA) introduced the bill in the House.
It is refreshing to see lawmakers follow the medical advice of addiction medicine specialists over the advice of cops.