Three Ways Substance Use Disorder Treatment Practice Rules Are Evolving

Physicians no longer need to have a special waiver to prescribe medication-assisted treatment

Typically, if you are injured or have surgery and need something stronger than ibuprofen for pain relief, your primary care doctor can prescribe an opioid medication called buprenorphine. But if you also needed that medication to treat substance use disorder (SUD), your doctor would need specific training (known as an X-waiver) in order to prescribe an opioid medicine to help in your recovery. Federal legislation signed in late 2022 did away with this X-waiver, but stigma persists around prescribing medication for substance use disorder.   

Because of changing views of opioid medications over the last several decades, they became over-used for pain relief.  In the process, the idea of using opioid medications to treat substance use disorder became unpopular and stigmatized as replacing one drug with another.

“Some may say that taking medication to help with a chronic illness like substance use disorder means a person is not ‘sober,’” said Dr. Dheeraj K. Raina, medical director at Carelon Behavioral Health, an Elevance Health company. “I would say that person is sober, with the help of medication. I like to use the analogy of Type 2 diabetes. Some people with diabetes dive into changing their eating habits and losing weight, to the point they may not need medications. Others don’t, and they’re effectively on medication for their lifetime, managing their condition. In both cases, they are in recovery from their chronic illness.”

Methadone can and should be dispensed from pharmacies

Methadone is an opioid pain reliever that is safe and effective when used as directed, and it was also the first drug used to treat opioid use disorder starting in the 1970s. Since that time, methadone could only be prescribed and dispensed from opioid treatment programs (OTPs), also known as methadone clinics. The rules were strict. A person could only get one dose at a time, so they had to go to the clinic every day, six days a week. However, OTPs are not plentiful; in fact, 70% of America’s counties do not have one.

“This makes the recovery process even more difficult, because it’s difficult to hold a job or take care of a family around the scheduling and availability of daily rides to an OTP,” Raina said. “Also, because methadone is only prescribed through methadone clinics, not through regular pharmacies, it doesn’t show up on prescription drug monitoring databases in every state when prescribed for substance use disorder. That’s a risk for doctors and patients, who may prescribe an opiate without knowing someone is also receiving methadone.”

The proposed federal legislation, the Modernizing Opioid Treatment Access Act would allow board-certified physicians and psychiatrists specializing in addiction treatment to prescribe methadone for substance use disorder and allow pharmacies to dispense methadone.

Telehealth is effective for treating substance use disorder, and the pandemic proved it

During the COVID-19 public health emergency, the DEA allowed an expansion of telehealth use for treating substance use disorder. The data shows that telehealth reduces overdose rates and helps people stay on track with their recovery. Telehealth makes it easier for doctors to check in with their patients, encourage their progress, and provide support.

Now, with fentanyl-related overdoses the leading cause of death for Americans under 50, more needs to be done to increase access to treatment. Buprenorphine is an effective option for treating opioid use disorder. It reduces cravings and enables an individual to adhere to a treatment plan.

“The requirement of an in-person visit before buprenorphine can be prescribed is a barrier to treatment,” Raina said, referring to the Ryan Haight Act. “If we can prescribe buprenorphine by telehealth when a person is ready for treatment, that would make it easier for people to begin treatment and increase their options for long-term recovery."

The in-person requirement of the act was waived during the public health emergency but will be required again in November 2023.

“Medication-assisted therapy for substance use disorder reduces the cravings for opioids and facilitates a sense of hope and expectation necessary to engage in recovery,” Raina said. “Expanding such treatment could be life changing.”

Further modernizing these rules and guidelines would remove barriers to care and improve continuity of care.