- No Rx Required? Faster Access to Opioid-Based Medication Could Save Lives
- Why is opioid use disorder treated with an opioid-based medication?
- What could be the biggest benefit of having buprenorphine available behind-the-counter?
- Have you seen the effects of buprenorphine in your own practices?
- Are there any similar medications for opioid use disorder that are distributed behind-the-counter?
- Given how serious this epidemic has become, what is your level of concern that this medication could be misused or abused?
- Opioid Epidemic with the North Carolina Department of Justice
- The Problem
- Legislative Response
- The Strengthen Opioid Misuse Prevention (STOP) Act
- The Synthetic Opioid Control Act
- The Heroin and Opioid Prevention and Enforcement (HOPE) Act
- The Solutions
No Rx Required? Faster Access to Opioid-Based Medication Could Save Lives
Photo by Joe Raedle/Getty Images
As of now, there are only three medications approved by the Food and Drug Administration to treat opioid use disorder, a disease affecting an estimated two million individuals in the United States.
Methadone, naltrexone, and buprenorphine are all opioid-based medications and require a prescription for use, which can make them difficult to obtain for people who urgently need them to avoid relapse.
But what if treatment was within reach without a visit to the doctor’s office? Boston University addiction experts Payel Roy and Michael Stein argue in a new editorial published in JAMA that lives could be saved by making one of these three medications, buprenorphine, more accessible to patients as a behind-the-counter drug monitored and administered by pharmacists.
Roy, a Boston University School of Medicine addiction medicine fellow and an internist at Boston Medical Center, sees patients every day who are struggling with opioid use disorder.
Stein, chair of BU’s School of Public Health department of health law, policy and management, provides primary care and buprenorphine treatment at a clinical practice in Rhode Island, which in 2003 was the first clinic in the state to start prescribing buprenorphine.
Roy and Stein spoke with The Brink to tell us more about why they think behind-the-counter buprenorphine could make a difference for people who are suffering from opioid withdrawal and don’t want to relapse to using drugs heroin or fentanyl or painkillers oxycodone.
Roy: I could go on and on about this. When it comes to patients, there is still a lot of stigma around medications used to treat opioid use disorder. People feel that they are “still addicted” if they use opioid-based medications buprenorphine as treatment, and prefer to try to stop on their own through meetings and groups.
The current research around addiction has suggested that addiction is a chronic disease–just high blood pressure and diabetes. So, medications to treat this disease should be the first-line treatment, as we know that it is extremely difficult to quit [using opioids] on one’s own.
Medical providers often exhibit stigma related to patients with opioid addiction, too, making it difficult for patients to trust the treatment community. Stigma gets in the way, but we also simply do not have enough treatment options for people.
If trying one or two of the three available medications isn’t effective, I don’t have many other options to treat my patients. For providers who do choose to treat patients with opioid use disorder, there are significant regulations around treatment.
To prescribe buprenorphine in particular, providers need to obtain a specific waiver from the Drug Enforcement Agency, which can bias many well-meaning clinicians into thinking that prescribing buprenorphine is too complicated or advanced for their practice.
Why is opioid use disorder treated with an opioid-based medication?
Roy: There are several treatments we use to help people with opioid addiction, including medications such as buprenorphine, methadone, and naltrexone, as well as behavioral interventions such as psychotherapy, Narcotics Anonymous, and other methods.
Opioid-based medications have some of the best efficacy for treating people with opioid addiction long term.
Illicit opioids heroin and fentanyl can cause addiction because they induce a euphoria very quickly, as well as an associated “low,” or withdrawal state, which causes people to want to use more.
Methadone and buprenorphine work because they can activate the same receptors that more addictive opioids heroin and fentanyl activate, but without causing a euphoria. This allows the addicted brain to slowly begin to recover from all the highs and lows of illicit opioid use so people are in a more “normal,” steady state.
What could be the biggest benefit of having buprenorphine available behind-the-counter?
Stein: When every dose of heroin or fentanyl could kill you, having immediate access to buprenorphine at a pharmacy—morning or evening—could be lifesaving.
Most heroin and fentanyl and prescription pill users use multiple times every day, whereas buprenorphine is long-lasting, requiring a single dose daily, limiting exposure to potentially lethal illicit opioids.
To me, this upside and the possibility of reducing overdose deaths mitigate my real concerns about this new idea.
I think it could do a few things. One is that we can help make the choice easier between illicit fentanyl or buprenorphine when people are feeling sick from opioid withdrawal. Another is that people could start on treatment right away, rather than waiting for a clinic appointment. Third, this process would reduce and hopefully eliminate the black market for buprenorphine. And finally, we would be legalizing what some of our patients are doing already, which is taking buprenorphine without a prescription. In fact, a person’s prior experience with buprenorphine, whether provided legally or illegally from a friend, predicts whether or not a patient will walk into my office looking for treatment. In that way, we hope that a low-barrier access model to buprenorphine may help reduce overdose deaths and encourage people with opioid addiction to enter into treatment.
Have you seen the effects of buprenorphine in your own practices?
Roy: It’s night and day, seeing patients when they first come in versus when they are stabilized on treatment.
Given the limitations I mentioned previously, not all of my patients stay on long-term; some come and go. But if you look at people who remain on treatment, you would have no idea they had an opioid addiction in the past.
My patients are able to regain custody of their children, run their own businesses. It’s truly remarkable.
Are there any similar medications for opioid use disorder that are distributed behind-the-counter?
Roy: Unfortunately, there is no similar medication at this time.
Other countries, Canada, have shifted to having pharmacists monitor buprenorphine dosages, so patients are dosed with their medication under supervision at the pharmacy counter.
We believe a behind-the-counter model would remove the need for a doctor’s prescription, but still allow for patient monitoring and careful tracking of the amounts of buprenorphine that people purchase.
Given how serious this epidemic has become, what is your level of concern that this medication could be misused or abused?
Roy: I am definitely less concerned about people with opioid addiction misusing buprenorphine compared with misusing more dangerous opioids oxycodone, fentanyl, or heroin. Given the way buprenorphine works, overdose risk is relatively low compared to other opioids.
People with opioid addiction will not feel a euphoria from taking buprenorphine, thereby limiting its potential addictive effects. While people can develop a physical dependence, addiction to buprenorphine is rare.
The main concern should be that if we make it available behind-the-counter, people who do not have an opioid addiction may develop one. Or, people with chronic pain might use buprenorphine to self-medicate. Lastly, just any other opioid medication, children may be accidentally exposed as it becomes more available in general.
It is for this reason that we have suggested some limitations, setting quantity limits, that should not hamper a person’s ability to obtain the medication they need, but can prevent overuse or misuse.
Opioid Epidemic with the North Carolina Department of Justice
The opioid epidemic is taking lives and tearing families apart across our state and the country.
More people die in North Carolina of an accidental drug overdose–usually an opioid–than from any other cause of accidental death.
Visit More Powerful NC to learn how communities across the state are taking action to take back their communities from the devastation of the opioid crisis.
Nearly every person in North Carolina has been touched in some way by addiction. Whether it’s through personal experience, or that of a family member or a friend, the opioid epidemic has hurt people all across our state.
- Five people die from opioid overdoses every day.
- More people die from opioid overdoses than car crashes.
- More than 2,000 North Carolinians died of an opioid overdose in 2017 – a 32 percent increase over the previous year.
- Between 1999 and 2017, more than 13,169 North Carolina residents have lost their lives to unintentional opioid overdoses.
- The number of unintentional overdose deaths in 2017 was nearly 17 times higher than in 1999.
- The number of unintentional opioid overdose deaths has more than doubled in the past decade.
Learn more at More Powerful NC.
North Carolina has responded to the opioid epidemic with three recent laws drafted by Attorney General Josh Stein’s office and sponsored by Representatives Greg Murphy and Craig Horn, Senators Jim Davis and Tom McInnis, and other members of the North Carolina General Assembly.
The Strengthen Opioid Misuse Prevention (STOP) Act
The STOP Act (2017) aims to reduce the number of people who become addicted to prescription opioids. The Act:
- Sets a 5-day limit for an initial prescription for acute pain (7 days for pain following surgery) to reduce the number of people who become addicted to pain medications and reduce the number of unused pills sitting in medicine cabinets
- Requires prescribers to check the Controlled Substances Reporting System database before prescribing opioids to reduce adverse drug interactions, duplicative prescriptions and doctor-shopping
- Requires electronic prescribing of opioids to cut down on prescription fraud
The Synthetic Opioid Control Act
The Synthetic Opioid Control Act (2017) helps law enforcement authorities go after fentanyl traffickers by ensuring that all derivatives of this deadly drug are classified as controlled substances under state law.
The Heroin and Opioid Prevention and Enforcement (HOPE) Act
The HOPE Act (2018) gives law enforcement authorities tools for addressing the opioid epidemic. The Act:
- Ensures that our drug trafficking laws cover trafficking in the deadly drug fentanyl
- Gives law enforcement quicker access to the information they need to investigate diversion of prescription drugs from legal to illegal uses
- Protects patient safety by strengthening laws against theft of drugs by healthcare workers and first responders
- Expresses the General Assembly’s intent to provide greater funding for drug treatment and recovery services
To confront this epidemic, we need cooperation among law enforcement, medical prescribers, the public health community, and the treatment and recovery community. Prevention, treatment and enforcement are critical.
Prevention should educate both the people who misuse prescription drugs and the doctors and dentists who overprescribe them.
Our state particularly needs proven programs directed to young people to help them avoid risky behaviors. Illicit or non-medical use of painkillers is the highest for youth and adolescents.
Teens and young adults report that prescription drugs are easy to access and seem safer than other drugs. More than 20 percent of North Carolina’s 11th graders have taken prescription drugs without a doctor’s prescription.
After just a few days on an opioid, some patients’ brain chemistry begins changing to create an addiction. We must educate North Carolinians about the dangers of these medications if they are unneeded.
Learn more about prevention strategies and how you can get involved at More Powerful NC.
Because addiction can happen so quickly and has become so common, effective treatment is critical. Expert research shows that medication-assisted treatments address addiction and promote recovery – especially when paired with therapy and community support.
Unfortunately, there simply aren’t enough treatment programs around the state. Funding is wholly inadequate. That’s something we must value more and solve.
Learn more about treatment and recovery, and how you can get help for yourself or someone close to you at More Powerful NC.
We need to effectively enforce our criminal laws on this issue. It is critical that we aggressively pursue the dealers and traffickers who push heroin on people with opioid addictions. Heroin is much cheaper and more readily available than prescription opioids. And it’s even more deadly.
Someone who has substance use disorder has a chronic illness. Jail time is not the best way to treat addiction. At four times the cost, prison is less cost-effective than treatment.
Helping someone treat their addiction is better for the person, their family, and their community. While in treatment, the person can live at home, provide for their family, get healthy, work, pay taxes, and contribute to society.
Naloxone, or Narcan, is a drug that can reverse an opioid overdose. Across North Carolina, it’s been administered 6,000 times by community members and first responders to save lives. We must work with law enforcement to make sure police departments and sheriff’s offices have access to this life-saving drug.
To get help, get involved, and get the facts, visit More Powerful NC.