Comment; It’s totally ridiculous to continue caps & limitations on buprenorphine prescribing.  BUP coverage should be mandated for ALL 3rd party payers, it’s such a superior treatment to methadone!



More than a decade into the opioid epidemic, illicit fentanyl is driving the nation’s rising overdose death toll. This cheap, powerful drug and other synthetic drugs like it are involved in nearly half of the roughly 200 overdose deaths that occur daily in the United States, according to federal data.

Preventing deaths requires progress on a range of fronts: addressing the factors that cause people to start using opioids, including over-prescribing in health care; supporting strategies that prevent overdoses and other adverse consequences for drug users; stemming the illicit drug supply through law enforcement; and improving treatment and recovery options for individuals using opioids and other drugs.

When it comes to treating opioid use disorder, the gold standard of care combines Food and Drug Administration-approved medications with behavioral therapies, such as counseling. Compared to other treatments that do not include medication, this medication-assisted treatment (MAT) significantly increases patients’ adherence to treatment and reduces illicit drug use.

Since patients are less likely to engage in risky behaviors such as injecting illegal drugs, MAT decreases the transmission of infectious diseases such as HIV and hepatitis C and reduces the danger of overdose deaths from fentanyl and other drugs.

Unfortunately, there is a massive gap in getting people treatment. Approximately 20 million Americans struggle with dependence on drugs or alcohol, but only one in nine receive any kind of treatment. According to a study in the “Journal of Addiction Medicine,” nonevidence-based methods are still prevalent: Only 23 percent of publicly funded treatment facilities offer MAT drugs and fewer than half of private sector facilities report using MAT. Unfortunately, many people who want help simply can’t get it.

President Donald Trump is expected to sign a wide-ranging opioid bill passed by Congress in October. In an effort to deter fentanyl shipments, the SUPPORT for Patients and Communities Act requires the U.S. Postal Service to obtain the same kind of basic information from all international shippers — including the name of the shipper, the name of the receiver and the contents of the package — that FedEx and other private shippers already require.

In addition, the legislation works to expand access to MAT in several ways. First, it ensures Medicare coverage of methadone, one of the three FDA-approved medications for opioid use disorder. The act makes the medication a covered Medicare benefit and will allow beneficiaries to receive this treatment in state and federally regulated treatment programs. Unfortunately, the new measure still does not mandate coverage of methadone in Medicaid programs, the insurance program for low-income individuals that cover one in five Americans.

The act also loosens federal restrictions on Medicaid funds used for residential treatment centers with more than 16 beds. The right care regimen for each individual depends on many factors, including the severity of the disorder, other diseases and conditions patients may suffer and the stability of their personal circumstances. Some patients may require inpatient treatment (which should not be confused with residential “detox,” which often fails to provide access to MAT or continuing care after discharge). However, outpatient or community-based settings provide appropriate care for most patients. Importantly, the law ensures that both outpatient and residential treatment are part of the continuum of services offered by a state’s Medicaid program.

The bill also expands the ability to prescribe buprenorphine, another FDA-approved medication for opioid use disorder. It expands beyond doctors to permanently allow nurse practitioners and physician assistants to prescribe the medication and creates a five-year trial period during which other providers, such as clinical nurse specialists, can become qualified prescribers. The measure also raises federal limits on the number of patients each provider can treat with buprenorphine. Looking forward, it will be important to evaluate whether the caps and mandatory federal training, which are not required for any other drug, are serving to protect public health.

The new act takes the right direction, but there’s more to be done. Millions of Americans struggle with substance use disorder — not only opioids, but also other legal and illicit drugs. Progress depends on addressing the epidemic at multiple points. State, local and federal officials must redouble efforts to provide treatment to those who need it.

Dr. Raymond Oenbrink
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