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I missed both the annual spring national ASAM (American Society of Addiction Medicine) meeting and our annual spring state NC SAM meeting over the past two weeks. I hated to miss them, but it was for a good reason. I took time to visit family I hadn’t seen in years, including aging relatives who won’t be around forever.

To make up for missing these fantastic educational opportunities, I’ve been reading recent journals and I found some gems I readers might find interesting. 

In the March/April 2022 edition of the Journal of Addiction Medicine, I read an informative review article of various states’ laws which have been passed to regulate office-based buprenorphine treatment of opioid use disorder. The lead author was Dr. Barbara Andraka-Christou.

As we know, the DATA 2000 law made it legal to treatment opioid use disorder in an office-based setting using buprenorphine products. This Act did require prescribers to complete a training and obtain a special “X” DEA number, and it also limited the number of patients who could be treated at any one time. Other than these two things, there were few added regulations, because the purpose of DATA 2000 was to make it easier for patients to get treatment, without the tradition regulations that are placed on opioid treatment programs (OTPs).

But some state legislatures felt DATA 2000 was too loosey-goosey and got busy passing more restrictive laws. The authors of this article grouped these restrictive laws under a few themes:

-Provider credentials and continuing medical education requirements

-Objective symptoms that new patients must exhibit before initiating buprenorphine prescriptions

-Educational requirements for new patients

-Counseling requirements, setting minimums on counselor credentials, or frequency or type of counseling necessary

-Patient monitoring including prescription medication program monitoring, mandatory minimum frequency for drug screening, and other things

-Enhanced clinical monitoring, mandating the minimum contact frequency or health assessment requirements or treatment planning requirements

-Patient safety requirements including mandating the co-prescribing of Narcan, use of the combination product versus monoproduct, and other things.

The authors voiced concern that these more restrictive laws might interfere with patient access to treatment, at a time when access is needed to prevent more opioid overdose deaths. The ten states that passed laws were West Virginia (which has the unfortunate distinction of being number one in opioid overdose deaths), Ohio, Kentucky, Vermont, North Carolina, Tennessee, Indiana, Florida, Virginia, and Alabama.

The authors of this article say that their study of these states’ laws raise three concerns.

First, they point out that some laws aren’t based on strong evidence. As an example, they cite laws passed that require some minimum counseling frequency. Literature reviews about this issue show mixed results about the effectiveness of adding counseling to buprenorphine treatment. Patients who are unable or unwilling to participate in counseling could be excluded from treatment with these regulations. For example, West Virginia dictates that weekly counseling must be done for the first ninety days of treatment, and at least twice per month for the rest of the first year. Patients who can’t or won’t meet those minimum requirements can’t get treatment at office-based programs. I’m sure intentions were good, but result is that the state which leads the nation in opioid overdose deaths placed an extra burden on patients seeking treatment which may or may not benefit them.

Don’t misunderstand me. I advocate for quality counseling in all patients, but I don’t advocate excluding patients who can’t or won’t participate.

Second, these state regulations resemble those placed on Opioid Treatment Programs, though DATA 2000 was passed purposely to give easier access than that seen with OTPs. Not to brag, but I said this back in my blog post of February 11, 2018, when I pointed out that Tennessee’s office-based buprenorphine laws were nearly as burdensome as the laws around opioid treatment programs (OTPs), defeating the whole purpose of DATA 2000.

Other examples of regulations include West Virginia’s law for a mandatory call-back plan to control diversion of medication, reminiscent of the diversion control plans OTPs must follow. Also, going a bit further than the regulations on OTPs, Kentucky’s law demands that before prescribing buprenorphine products to a pregnant patient with opioid use disorder, the physician needs to get a written concurring opinion from a board-certified Addiction Medicine physician.

 I don’t know how many board-certified physicians in Addiction Medicine Kentucky has, (maybe fewer now, after that weird law was passed), so that requirement seems restrictive. What’s a pregnant patient to do? In the rest of the healthcare world, these patients are given the highest priority access to treatment

 And third, some of the laws resemble those placed on pain clinics, which are meant to limit unsafe prescribing. But buprenorphine treatment is safer and has much more evidence of benefit than the treatment of chronic pain with opioids. Tennessee’s law limiting a patient’s daily dose to 16mg or less is one example of these types of laws. We have data that indicates patient retention in treatment is better with higher doses, so most practitioners have abandoned the once-popular idea the less buprenorphine is better.

Reminiscent of requirements around pain clinics, some of these ten states have asked providers who prescribe buprenorphine products to register with their state officials. Thankfully, North Carolina repealed this regulation several years ago.

Why did the states with the worst problems with opioid use disorder pass laws that limit treatment access? The authors don’t offer answers, be we can guess.

I think that states with legislators who are less aware of the science around substance-use disorders in general, and of evidence-based treatments for opioid use disorder in specific, are more likely to pass laws that inadvertently make the situation worse. It’s important for all workers in the Addiction Medicine field to makes efforts to educate their legislators.

I’m grateful I live in North Carolina, where legislators sought information and input from Addiction Medicine specialists. They’ve made great efforts to make wise decisions and continue to do so when considering how to spend the opioid settlement money, as you can read about in blogs from January 6 and January 20 of this year.

In North Carolina, our state’s Department of Health and Human Services formed a committee called the North Carolina Opioid and Prescription Drug Advisory Committee, or OPDAAC for short. The purpose of this committee was to plan implementation of the state’s Opioid Action Plan, but the meetings expanded to include anyone with an interest in working on the state’s problem with opioid use disorder. They invite experts and stakeholders to speak at their meetings, giving a diversity of opinions and a chance from committee members to learn from each other.

I think these efforts have helped form better public policy in our state. It may not be perfect, but it’s improving, leading to more patients getting the help they need.

There’s a lesson for other states.

4 responses to this post.

  1. These laws are all so typical of legislators who think they know it all but don’t. It’s simple legislators have no business making regulations. You need the experts. But this can backfire too when they are pretend experts that promote abstinence oriented treatment. When this happens it’s worse because you have pretend experts who will do everything to keep MOUD (Medication for Opioid Use Disorder) out. And they claim to be experts.

    Reply

    • Posted by Majority Ruhl on April 23, 2022 at 8:06 pm

      Truthfully you don’t even need a degree to be considered an “expert” when it comes to opioid addiction! Unfortunately most of the experts I know received their education regarding opiates for free!! Not that anyone ever asks them for suggestions!

      Reply

  2. Posted by AbamAsam Doc on April 18, 2022 at 12:53 pm

    Thank you! Addiction Specialists are completely left out of conversations that lead to regulations. Legislators seek out a few Addiction Medicine specialists from Inpatient sobriety based treatment centers to co- sign their agendas. These always being more restrictive in nature & never evidence based. Regulation wording being “cut & pasted” from OTP’s & even state psychiatric facilities, i.e., “we will not restrain patients or coerce them into making any statements”. Restrictive Bills are passed without warning that retroactively effect practices. Patients continue to suffer as the result of these restrictions

    Reply

  3. Posted by Charlie on April 18, 2022 at 2:36 pm

    Dr. Burson, you are being, understandably, diplomatic. Most if not all of those states have Republican governments. They are notoriously anti-science

    Reply

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