Almost two decades ago, Jennifer Michaels became the first person in Berkshire County to prescribe buprenorphine.
Those early prescriptions saved lives, said Michaels, who serves as medical director of The Brien Center, but they came with stigma attached.
“It was a bizarre dichotomy,” Michaels said. “On the one hand, I was treating patients who had struggled for months or years with potentially fatal heroin addictions and, once stabilized on Suboxone, were able to go on with their lives. On the other hand, I was being criticized, shamed and ostracized by some of my colleagues in the field for practicing this evidence-based treatment.”
One of her early patients started taking the drug, commonly known under the brand name Suboxone, after years of heroin addiction and relapses. He remains stable, on Suboxone, to this day.
Despite evidence that the opioid use disorder treatment could save lives, though, her peers would harass her. Therapists and counselors trained in abstinence-only treatments would tell her she was swapping one drug addiction for another. One man came into her office and accused her of using “Nazi tactics” to treat patients. Another posted a derogatory video of her online.
“It wasn’t just disheartening,” she said. “It was scary.”
On Tuesday, Michaels watched as the Biden administration dramatically reduced barriers to buprenorphine access — lowering regulatory hurdles and expanding the number of health care providers who can prescribe the drug.
For the first time ever, a wide swath of providers, from doctors to certified nurse midwives, can give out the drug almost as easily as other medications, the latest sign of increased acceptance of medication-assisted treatment for opioid use disorder.
“This is really good news,” Michaels said. “Not only will it increase access, I’m hoping it will help providers to feel more comfortable treating people who have opioid use disorder.”
Buprenorphine helps people control opioid cravings, and has been proven to reduce relapses and overdose deaths. The drug binds to the same brain receptors as heroin and other opiates, blocking their effect.
While buprenorphine can produce some euphoric effects, studies show it has, by far, the lowest abuse potential of any opiate, and its “ceiling effect” means that an increase in dosage beyond a certain point has no impact.
Suboxone is a mix of buprenorphine and naloxone, which further prevents abuse. Unlike methadone, Suboxone does not have to be administered regularly at a specialized clinic, which gives patients more independence.
Previously, doctors and other providers could prescribe buprenorphine only after they underwent separate training and received a waiver, called the “X-Waiver.” This year, the U.S. Department of Health and Human Services estimated that just 6.6 percent of the country’s physicians had a waiver.
The new rules nix those mandates for anyone treating up to 30 patients with the drug. They come as opioid deaths have surged across the country, driven, in large part, by the prevalence of fentanyl, a synthetic opioid significantly more powerful than heroin.
According to federal estimates, more than 87,000 people in the U.S. died of drug overdoses during the 12-month period that ended in September, the largest annual death toll since the opioid epidemic began.
The same increase has played out in Massachusetts, as anecdotal reports from addiction treatment providers and law enforcement suggest a rise in fatal overdoses in Berkshire County.
“Not only are we in the middle of the COVID pandemic, we’re in the middle of a worsening opioid epidemic,” Michaels said. “Anecdotally, we’re seeing more people are isolated, using alone and at risk.”
Certified providers have been able to prescribe buprenorphine since 2002, after the passage of the Drug Addiction Treatment Act of 2000. Over nearly two decades, stigma around the treatment has persisted, even as the pushback has grown subtler.
“People still refer to medications like methadone and Suboxone as replacing one drug with another,” Michaels said. “Two decades later, we still have all this misinformation.”
As recently as the mid-2010s, Berkshire County still had Suboxone prescribers and “huge gaps” in understanding, according to Jennifer Kimball, coordinator of the Berkshire Opioid Abuse Prevention Collaborative.
“It was common to discharge people who’d gone through detox and some rehab with absolutely no medications on hand,” she said. “They’d wait maybe up to 10 days or more to find a prescriber.”
These days, Kimball said, many patients who leave detox or rehabilitation programs can get a prescription within 24 hours. But, only a small fraction of people with opioid use disorder receive any treatment at all. Advocates hope that the reduced regulation will create more points of contact for people who could benefit from medication-assisted treatment.
“We’ve come a long way in Berkshire County to addressing opioid use disorder, and this just takes us one step further toward no- or low-barrier service,” Kimball said. “Treatment on demand for everyone is the goal here.”
Like other advocates for expanded buprenorphine availability, Kimball pointed out the irony that doctors need a waiver and special training to prescribe Suboxone but freely can give out prescriptions for Oxycodone, one of the most commonly abused drugs in the country.
The Brien Center has resources available to new Suboxone providers, and can advise on best practices and answer questions, Michaels said.
“Any provider can prescribe the medication and begin to see that it’s not that complicated, that people do recover from opioid use disorder when they’re treated with respect and evidence-based treatment,” she said. “My suggestion for providers is, just treat one person in your practice who’s struggling with opioid use disorder. Get comfortable.”
She hopes that more clinicians will see and treat opioid use disorder like they would tackle any other chronic disease.
“We don’t say, ‘When are you getting off that stuff?’ to people who need insulin for diabetes,” she said. “So, why are we saying that for medications like Suboxone?”