By Ryan DuBosar
Congratulations, doctor, you've gained the ability prescribe buprenorphine to treat patients with opioid use disorder, and you didn't need to take any action to earn that privilege.
With this permission, all primary care physicians should know how to use this drug, said Ann R. Garment, MD, FACP. Effective January 2023, legislation removed a prescribing requirement called the X waiver, the complexity of which had been a barrier to prescribing buprenorphine. Now, physicians with a standard U.S. Drug Enforcement Agency (DEA) registration number can begin prescribing it.
"If you are prescribing Percocet, you can prescribe buprenorphine," said Dr. Garment, who is medical director of the Primary Care Addiction Medicine Clinic and section chief of general internal and hospital medicine at NYC Health + Hospitals/Bellevue. (Starting June 27, 2023, the DEA requires one-time attestation of eight hours of training on management of substance abuse disorders prior to renewal of all DEA registrations.)
The rewards of the drug are immediate for physicians and patients, Dr. Garment said. "When you're able to get a patient's opioid use disorder under control, the impact you see on their life happens within weeks to months," she said. "We've got folks who are now addressing their chronic medical conditions, who are uniting with their families, whose housing is stabilized, [who are] getting employment."
And now is the time to make those improvements, she added. The U.S. is in its third wave of opioid overdose deaths, following one in 1990 when pain was touted as a fifth vital sign and another in 2010 when federal legislation restricted opioid prescribing, which increased heroin use. "We're now unfortunately in the third wave of overdose deaths, which really are largely due to synthetic opioids. And what we're really talking about here is fentanyl," Dr. Garment said.
Buprenorphine is effective because it is safe, Dr. Garment said. "And I'm going to argue that buprenorphine is safer to prescribe than Coumadin, than insulin," she said. "Everyone should feel like they can prescribe this medication."
At lower doses, it prevents opioid cravings, but at higher doses, there's a ceiling effect that prevents opioids' risk of respiratory depression, overdose, and death. "This is a medication that is going to treat opioid use disorder, but you will not get very bad side effects from it, which is amazing," Dr. Garment said.
Buprenorphine is also a "sticky" medication with a high affinity for opioid receptors, she said. In a patient taking buprenorphine who uses heroin, buprenorphine will be more tightly bound to opioid receptors than heroin.
In addition, patients using benzodiazepines can add buprenorphine, despite the risks of using two drugs that cause sedation, Dr. Garment said. In 2017, the FDA said the harm caused by untreated opioid addiction can outweigh the risks of combining benzos and opioids. "Just counsel your patient on if they can make an informed decision," she said. "It is almost certainly safer than what they're already doing."
One important note is that patients should be in mild to moderate withdrawal before taking the medication. Wait for symptoms to get bad, she said. "For most patients, it's about 12 hours. For more of my patients, it takes about 24 hours for them [to be in] enough withdrawal for them to start." ■