All attempts to get physicians involved in the battle against the opioid and alcohol epidemic have failed. Why the failure? A more relevant question to ask is: Is it necessary, and could it even be a hindrance? We need to look at the past and present to find answers.
Less than 10% of the 23 million patients impacted by drugs and alcohol receive medications (SAMHSA, 2021). This is a shocking number but not a surprise. Part of the reason is that we have just six medications available, with two—methadone and buprenorphine—facing restrictions on prescribing them.
The treatment of alcoholism is dominated by self-help groups like AA and 12-Step programs that generally eschew medications. Attempts to “medicalize” the treatment have not been successful. Meanwhile, the treatment of opioid addiction is dominated by opioid substitution therapy with either methadone or buprenorphine (McLellan, 2017). Methadone is a highly regulated drug administered in a clinic setting. The restrictions on buprenorphine were once considered onerous, with less than 5% of U.S. physicians obtaining the now-waived DEA waiver to prescribe it.
There is much we can learn from the phenomenal success of naloxone (Narcan). This prescription medication, approved in 1971, languished for decades before the opioid epidemic prompted a shift in perspective. The major bottleneck for utilizing this highly effective and safe reversal agent was the prescription requirement. Most states issued statewide prescriptions for naloxone, allowing patients to obtain it without visiting a physician. Harm reduction organizations were able to secure bulk supplies, making this life-saving medication widely available. The FDA eventually granted naloxone OTC status, and now millions of doses are accessible without restrictions (House Hearing, 113th Congress).
Why stop at naloxone? Naltrexone, closely related to naloxone, should be the next medication to follow. It is highly effective at preventing relapse to opioid use, a significant issue given the ubiquity of illegal opioids like fentanyl. Naltrexone is also approved for treating alcoholism, a growing problem since the COVID-19 pandemic. This medication can be utilized in two ways: to maintain sobriety or to reduce drinking. Issuing a statewide prescription for naltrexone would greatly increase access to this highly effective treatment.
A Two-Step Approach
A two-step approach could significantly advance the fight against opioid and alcohol use disorders:
Remove the prescription requirements for all FDA-approved opioid antagonists.
Allow all licensed physicians with a valid DEA license to prescribe buprenorphine and methadone.
References:
Substance Misuse and Substance Use Disorders: Why do Many Fail to Receive Treatment? - Discusses barriers to medicalizing addiction treatments.
Results from the 2021 National Survey on Drug Use and Health - Highlights statistics on substance use and treatment gaps.
Examining the Growing Problems of Prescription Drug and Heroin Abuse - Covers regulatory challenges and naloxone access.
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