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Key points
- Buprenorphine is a safe, evidence-based medication for opioid use disorder that can control drug cravings and prevent overdose deaths.
- Despite its safety profile, buprenorphine is under-prescribed, due to a lack of medical provider training, as well as stigma.
- The federal government recently lifted a regulatory burden on buprenorphine, but patients still need to advocate for access the medication.
More than 100,000 people are dying of drug overdoses each year in America, driven chiefly by opioids.
Medications can prevent opioid overdoses by blocking the effects of deadly drugs while also controlling cravings to use those drugs. Yet, they are vastly underutilized. Less than one-fifth of people in need of medications for opioid use disorder (OUD) receive them.
One of the evidence-based medications for OUD is buprenorphine. Approved by the FDA in 2002, until recently it could only be prescribed by providers who took a special course and applied for a waiver, known as an X-waiver. At the end of last year, the federal government lifted this regulatory burden. It remains to be seen whether this change will save lives.
The two other FDA-approved medications for OUD, methadone and naltrexone, have more limited use. Methadone cannot be written as a prescription for OUD but rather must be dispensed by a federally certified clinic. Naltrexone is available as a prescription but is less effective than buprenorphine or methadone.
People in need of OUD treatment should seek treatment settings that offer medications, in particular, buprenorphine.
How Does Buprenorphine Work?
Buprenorphine is a partial opioid. It attaches to opioid receptors in the brain, just as heroin, fentanyl, and other full opioids do—but relative to other opioids, buprenorphine activates those receptors weakly. Think of a lackluster opening act when you go to see a show—it’s enough to keep you in your seat, but it’s not the main performance.
Buprenorphine can control cravings to use other opioids, but as long it is dosed properly, it does not cause intoxication or suppress breathing, which is the mechanism of opioid overdose. Now, imagine if that bland opening act refused to leave the stage, keeping the main act stuck behind the curtain. That is how buprenorphine prevents overdoses: it clings more tightly to the opioid receptors than full opioids do. When people use other opioids while on buprenorphine, they do not get high or stop breathing.
Why Is Buprenorphine Underutilized?
For most of history, addiction was stigmatized as a moral failing. It was not until 1997 that the National Institute on Drug Abuse introduced the concept of addiction as a brain disease, and not until 2012 that a landmark report connected the growing issue of untreated addiction to a dearth of medical training. Even today, many drug treatment programs consider recovery to mean abstention from use of all opioids; they do not consider a person who is taking buprenorphine to have achieved recovery.
The recently revoked X-waiver also posed a barrier; fewer than 100,000 clinicians in the country had one as of January 2021. Given the irony that no such waiver was required to prescribe the oxycodone, Percocet, and other full opioids that delivered us an epidemic in the first place, the X-ing of the X-waiver is a cause for celebration.
Yet it is premature to declare victory in the struggle for broad access to buprenorphine. One study that assisted clinicians in obtaining an X-waiver, including providing the requisite training course, found that the majority did not use the waiver. Medical training curricula have a gaping hole when it comes to addiction, one which a single course cannot fill.
Starting buprenorphine can be tricky. If initiated too soon after the last use of a full opioid, it will displace that full opioid from its receptor in the brain, precipitating a sickness known as withdrawal. Sometimes described as “leaking from every orifice,” withdrawal involves watery eyes, a runny nose, vomiting, diarrhea, and more. Imagine if the boring opener pushed the headliner off the stage mid-act—the audience would be pretty miserable. On the other hand, if the main act suddenly left mid-performance, the opener could step in to fill the time, cheering everyone up. Similarly, once a person with opioid dependence is already experiencing significant withdrawal, buprenorphine can soothe the symptoms.
How Can These Barriers Be Overcome?
With appropriate education, patients can start buprenorphine at home without precipitating withdrawal. Inpatient and residential facilities can observe patients until they have reached the appropriate stage of opioid withdrawal for buprenorphine to alleviate rather than exacerbate their symptoms.
Many rehab facilities do this already—only to stop buprenorphine once the withdrawal has resolved. They may claim that at this point the patient has completed “detoxification,” or “detox,” but the use of these terms can perpetuate the stigma that a person who uses drugs needs to be “cleaned” in some way. Moreover, addiction is a chronic medical condition that warrants treatment with maintenance medications, just as, for instance, diabetes management may require long-term use of insulin. Limiting the use of medications to the withdrawal phase disregards clinical reality and undermines recovery.
Rehab facilities bear a special responsibility to not only start buprenorphine but also to link patients to a community prescriber who will continue the medication after discharge. Buprenorphine can control the cravings to use drugs that are triggered by the stressors of returning to the real world after rehab. Moreover, while sequestered at rehab, people lose their tolerance to opioids. With their bodies no longer accustomed to using the amount of street drugs that they used before, they are especially vulnerable to a fatal overdose—which can be prevented with buprenorphine.
How Can People With OUD Access Buprenorphine Treatment?
If a patient with OUD is safe in their current home environment, they can start buprenorphine while remaining in the community. You can find outpatient buprenorphine prescribers here.
If you or your loved one is seeking inpatient or residential treatment for OUD, inquire about each facility’s policy on buprenorphine. This means asking not only whether they provide short-term buprenorphine for withdrawal management (or “detox”) but also whether they support long-term use, including providing a bridge prescription to last until patients establish with an outpatient prescriber.
By asserting a right to evidence-based treatment, patients and their loved ones can erode the stigma against medications that has clung to the addiction treatment world for far too long.
