It has become an all too familiar (but no less disturbing) scenario for the nurse practitioner working in a large drug treatment center in upstate New York. Today she is leading an educational support group for individuals who are opiate dependent and awaiting medication assisted treatment with buprenorphine/naloxone (brand names: Suboxone or Zubsolv) or Buprenorphine (brand name: Subutex). The topic today is overdose prevention and group participants share their stories. Tom a 20-year-old well groomed, athletic, male tells the group that four months ago he had his fourth heroin overdose. “I’m not sure why I’m still alive. I was dead for 20 minutes during resuscitation attempts. I knew I was at risk after my first overdose but I was out of control and could not stop. I had to keep using heroin. I’m still shooting just enough to keep from getting sick until there is an opening for me to see the doctor who prescribes buprenorphine. I’ve been on the waiting list for a month.”
Jamie spoke next. He is 19 years old and had been using prescription opiates since a motor vehicle accident three years ago. At first the “hydros” (street name for hydrocodone) were for pain. Eventually, his pain resolved but his use of opiates continued. Soon he was buying prescription opiates, “off the street” until they became too hard and too expensive to obtain. “A friend of mine introduced me to heroin which was much cheaper and much easier to get. I have overdosed three times in the past six months and I was admitted to an ICU two of those times. I still owe $30,000 in ambulance bills alone. While I wait for my buprenorphine appointment (he’s on the waitlist too), I’m buying Subs (street term for Suboxone) off the street.”
Perhaps most disturbing of all was Andrew, age 45, who has been using intravenous heroin since age 11. “Once I woke up on a gurney in a morgue surrounded by dead people on either side of me. Someone must have mistaken me for dead and brought me there. I pulled the sheet off of my face, wrapped it around me and got up and started running. I think I gave the coroner a heart attack!” The group laughed nervously at this unbelievable scenario. With a sense of frustration, the group facilitator wonders if/when she will be able to prescribe buprenorphine, which seems to her one viable option to improving access to treatment for individuals with opiate use disorders (OUD). She cannot help but wonder how these clients will fare while they await their appointments to receive buprenorphine. Some of them have already been waiting several weeks and are anxiously awaiting a call for an appointment. What if there was just such a waitlist for insulin? Because the individuals in this group are at high risk for yet another overdose, the NP introduces the topic of overdose prevention.
With consequences like overdosing, why don’t they just stop? The answer is altered brain chemistry, genetics, and life circumstances, not moral failing. Extended opiate use causes changes in brain chemistry, structure and function. These changes result in relentless, intense cravings that override all other normal judgment and decision-making. Persons addicted to opiates need time for their brain and body to heal. What is known definitively is that the most effective treatment for OUD is counseling with medication assisted therapy.
Opioid dependence represents a serious public health problem affecting a growing number of individuals in the United States. It is estimated that there are 1 million heroin addicted individuals in need of treatment and nearly 2 million untreated prescription opiate dependent people in the United States (NSDUH, 2011). The opiate overdose statistics are just as staggering. Fatal overdose from opiate medications such as oxycodone, hydrocodone and Fentanyl have quadrupled since 1999 accounting for an estimated 16,651 deaths in 2010 (these are prescription opiate overdoses only and do not include overdoses caused by heroin). Interestingly, there has been a 5% decline in opiate analgesic death rates from 2011 to 2012. This represents the first decrease seen in more than a decade (Warner, Hedegaurd).
One explanation for this decline is in part due to much needed and essential legislation that makes obtaining prescription opiate analgesics more difficult. For example, the prescription drug monitoring program (PDMP) is a statewide electronic database of prescriptions dispensed by pharmacies for controlled substances. This information can be used to help identify or prevent drug abuse or diversion, facilitate the detection of patients who may have an addiction problem, and inform and educate public health agencies and health professionals about the use, abuse and diversion of prescription drugs (PDMP Training and Technical Assistance Center www.pdmpassist.org).
Unfortunately, there has been a ripple effect of stricter policies regarding prescription opiate analgesics. That is, a resurgence in the widespread use of heroin which is a cheaper and more readily available illicit and potentially lethal opiate. In 2013 there were 169,000 persons aged 12 or older who used heroin for the first time in the past 12 months compared to 90,000 individuals in 2006 (US Department of Health and Human Services, 2013). On January 12, 2015, The White House Office of National Drug Control Policy (ONDCP) announced the 2013 drug overdose mortality data from the Center for Disease Control and Prevention (CDC). The data shows that the mortality rate associated with heroin increased for the third year in a row representing a 39 % rise from 2012-2013 (Office of National Drug Control Policy, 2015).
Like diabetes and hypertension, chemical dependency is considered a chronic medical condition and often requires ongoing management with a combination of treatment modalities. Because of the complex changes that occur in the brain both structurally and chemically with substance use disorders, outcomes rely on a variety of factors including the individual’s motivation for recovery and access to treatment (outpatient, inpatient, or residential treatment centers). Once in treatment for an OUD there are three options for medication assisted treatment (MAT); Methadone, Naltrexone/Vivitrol, and Buprenorphine.
- Methadone is a full opiate agonist and is an effective, evidenced-based treatment for opiate dependence. However, it requires that individuals receiving methadone obtain their daily dose from a federally qualified methadone clinic.
- Naltrexone (oral form) and Vivitrol (intramuscular injection form) is an opiate agonist and is designed to block the desired opiate response. An individual must be opiate-free for 7-10 days prior to starting
this medication, making it very difficult for someone in active addiction to abstain from using an opiate for that length of time. If a patient is able to abstain, or if s/he has already had a period of abstinence from opiates, this is a safe, effective, non-narcotic, MAT. It is utilized for both opiate and alcohol dependence.
- Buprenorphine is a partial opiate agonist and antagonist has been used for opiate use disorders since 2000. It can be prescribed and monitored in an outpatient office setting. Buprenorphine is a safe, effective alternative to methadone and has been associated with increased treatment retention and survival as well as fewer adverse side effects (Wally et al., 2008). Unlike methadone, buprenorphine has a ceiling effect that enhances patient safety by reducing the risk of overdose (SAMHSA, 2010). Buprenorphine is prescribed as part of an outpatient office visit and also unlike methadone, does not require daily visits to a specialized clinic.
One of the barriers for better access to treatment with Buprenorphine is that only “qualifying physicians” (those that complete minimally an eight-hour course in opiate dependence) may prescribe buprenorphine for the purpose of treating individuals with OUD. Prior to the year 2000, buprenorphine was not yet utilized for the treatment of opiate addiction. The Drug Abuse Treatment Act of 2000 (DATA 2000) was passed and allowed “qualifying physicians” to treat a maximum of 30 patients with OUD at any given time with Buprenorphine (House Resolution 4365.2000). In 2006, this law was amended to allow the maximum to be increased to 100 patients after one year. Interestingly, Buprenorphine is the only Schedule III medication that existing laws permit only physicians to prescribe (House Resolution 4365, 2000). For reasons not clearly identified, nurse practitioners (and Physician Assistants) were excluded from DATA 2000.
More specifically, under DATA 2000, Nurse Practitioners (NP’s) are not permitted to prescribe Buprenorphine for the treatment of opioid dependence, as the term “qualifying physician” is specifically defined to include only physicians licensed under state law (House Resolution 4365, 2000). NPs can prescribe all other medications, including all controlled substances. Ironically, NPs can prescribe Butrans (a transdermal patch which contains buprenorphine) for pain management and sublingual buprenorphine (if used off label) for pain – but not buprenorphine to treat addiction (NP’s cannot prescribe methadone to treat OUD’s either, but this article is specifically about prescribing Buprenorphine).
DATA 2000 was a step in the right direction, but it has left a shortage of health care providers who can legally prescribe buprenorphine for opiate use disorders. This, in turn, results in people waiting several weeks to months before obtaining this often lifesaving treatment. While awaiting an appointment to receive buprenorphine, individuals are exposed to multiple risks, not the least of which is overdose and death.
There are ways to manage this ongoing and ever-increasing opiate epidemic which affects the lives of many. In July of 2014, Senator Ed Markey of Massachusetts proposed a legislative Bill (S. 2645) which called for the expansion of buprenorphine treatment by allowing NPs and Physician Assistants (PAs) to prescribe buprenorphine for opiate dependence and to permit physicians to have more than 100 clients on buprenorphine at any one time. Apparently, the bill “died in committee” and will need to be redesigned and submitted to The Senate with a compatible bill to The House of Representatives for reconsideration. As concerned citizens, medical providers, parents, siblings and neighbors, we can write, email and/or call local congressional representatives to express our concerns and to suggest viable alternatives for the treatment of OUDs. Again, this would include better access to treatment by allowing NPs and PAs to prescribe buprenorphine which is a safe, evidenced based often lifesaving treatment for patients with opiate use disorders and by lifting the 100 patient limits for physicians.
Controlled substances are used to treat a plethora of medical issues, including pain, epilepsy, and mental health disorders such as anxiety and ADHD. In the acute phase of a chronic medical condition, patients should not have to wait for treatment. What if you, a family member or someone you knew could not get care because treatment slots were limited. The answer to immediate access is as simple as amending a Federal law. The resources are already in place. Now, we need legislation in order to use those resources!
Christene Amabile, FNP-BC is a nurse practitioner working in the field of addiction medicine at Horizon Health Services, the largest behavioral health organization in the Western New York area. Paige Prentice is Vice President of Operations for Horizon Health Services and serves on the board of NYASAP (New York Alcoholism and Substances Abuse Providers).
References
House Resolution 4365. (2000). Drug Addiction Treatment Act of 2000. Retrieved from http://www.govtrack.us/congress/bill.xpd?bill=h106-4365
Warner, Margaret, PhD, Hedegaard, MD, MSPH and Chen, Li Hui, MS, PhD, Trends in Drug-poisoning Deaths Involving Opioid Analgesics and Heroin: United States, 1999-2012. NCHS Health E-stat. Hyattsville, MD: National Center for Health Statistics, December 2014, p.1.
National Survey on Drug Use Health (NSDUH), 2011. Results from 2011 National Survey on Drug Use and Health: Volume 1. Summary of National Findings. U.S. Department of Health and Human Services. Abuse and Mental Health Services Administration. Office of Applied Studies.
Office of National Drug Control Policy, 2013 Drug Overdose Mortality Data Announced. Prescription Opioid Deaths Level; Heroin-related Deaths Rise. Retrieved From www.whitehouse.gov/DrugPolicyReform, January15, 2015.
Substance Abuse and Mental Health Services Administration. (2010). About Buprenorphine Therapy. Retrieved from http://buprenorphine.samhsa.gov/about.html
The PDMP Training and Technical Assistance Center (PDMPTTAC), located @ Heller School for Social Policy and Management at Brandeis University. Retrieved from: www.pdmppassit.org.
U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality. CBHSQSAMHSA, Department of Health and Human Services, RTI international, September 2014.
Walley, A.Y., Alperen, J.K., Cheng, D.M., Bottticelli, M., Castro-Donlan, C., Samet, J.H., &Alford, D.P. (2008). Office-based management of opioid dependence with buprenorphine: Clinical practices and barriers. Journal of General Internal Medicine, 23(9), 1393-1398.
