With COVID-19, a need to deregulate buprenorphine prescriptions [PODCAST]

 

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“With COVID-19, we have both the unique opportunity and need to deregulate buprenorphine prescriptions. The Substance Abuse and Mental Health Services Administration (SAHMSA) recently updated guidelines for buprenorphine prescriptions. There are new provisions for telephonic initiation of buprenorphine and scripts up to 28 days for stable patients. Unfortunately, this does not circumvent the major issue: redeployed providers will not be able to fill scripts. With just 7 percent of providers nationally able to even prescribe buprenorphine, this is a particularly vulnerable window for care. We must instead take the current crisis as an opportunity to reform and strengthen MAT access.”

Megana Dwarakanath is a pediatrician.

She shares her story and discusses her KevinMD article, “With COVID-19, we have a unique opportunity and need to deregulate buprenorphine prescriptions.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Megana Dwarakanath. She’s a pediatrician, and she wrote the KevinMD article “With COVID-19, we have a unique opportunity and need to deregulate buprenorphine prescriptions.” Megana, welcome to the show.

Megana Dwarakanath: Thank you. I’m happy to be here.

Kevin Pho: So we’ll get to the article in a bit, but first off, if you could share your story and your journey to where you are today, that’d be great.

Megana Dwarakanath: Yeah. So I grew up in New Jersey, had a pretty normal Indian-American childhood over there, and then I went to college at Smith in Massachusetts, which is an all-women’s college and very progressive politically. I wasn’t sure at that time that I wanted to go into medicine, but it was a good opportunity to explore a lot of different interests. I ended up living abroad in Ethiopia for a year after I left Smith and was spending some time doing a public health project, which I think got me very interested in medicine, and also teaching at schools, which got me particularly interested in the adolescent population.

I went back to med school at Rutgers in New Jersey and then ended up doing a rotation at the Indian Health Services and really loved that, so I went to New Mexico for residency. And now I’m back on the East Coast at UPMC for adolescent med fellowship, with a big focus on substance use disorder.

That’s kind of been with me since medical school, with the populations that we served. And then definitely in residency, I worked at a clinic that was kind of a medical home for people that had left the juvenile justice system. And I also realized that pediatric training about substance use disorder, and comfort, was very poor, even though many of our patients had started using substances, and particularly opioids, in their teenage years when they saw us. So that was kind of what got me interested in working with adolescents and definitely opioid use disorder.

Kevin Pho: Sure. And how has the pandemic affected you and your practice?

Megana Dwarakanath: Actually, initially in New Mexico, there was a shift to try to get our patients in via phone calls. We weren’t quite doing telemedicine there, but we found that many of our patients relied on a lot of social supports, and with the pandemic, having their social worker check in on them at their home or getting a ride from a friend was very difficult because of the pandemic. And also, because we couldn’t cluster patients as much, we had to reduce the frequency of seeing our patients.

I had one patient, because I was also seeing adults in my clinic, who was doing actually very well abstaining from opioids, and she lapsed during the pandemic because she was kind of placed back in her home with a family member that was very triggering to be around, had not really had anybody by the house to check in on her, and was not able to go to church, where she had a support system. So we saw people really worsen in their ability to manage substance use disorder during the pandemic, and I think we’ll continue to see that.

Kevin Pho: Now, let’s get into your KevinMD article, “With COVID-19, we have a unique opportunity and need to deregulate buprenorphine prescriptions.” Now, for those non-clinicians in my audience, I was wondering if you could start by first explaining what buprenorphine is and why it is important.

Megana Dwarakanath: Yeah, sure. So buprenorphine is one of the few approved medical therapies for opioid use disorder. It works as a partial agonist, which allows it to have some effects of something like naloxone, where you don’t get any effect from it, and then also allows some of those mu receptors, which opioids also target, to be affected. This kind of reduces its propensity to be abused by injection or snorting.

But it is kind of a maintenance medication, so we typically treat it the way anybody would be taking insulin for diabetes or taking their blood pressure medications. It’s prescribed by a pharmacist. Our patients pick it up in a pharmacy. They don’t have to go to a methadone clinic, for example, where sometimes there’s a lot of stigma about being openly in a methadone clinic, or they perhaps are interfacing with people who were selling them drugs at the methadone clinic themselves.

And the nice thing about buprenorphine is they have a really nice schedule to taper on or off, depending on what the patient is comfortable with. There is lower potential for abuse, and our patients generally like the fact that it makes them less sleepy, if they were on methadone before, and that they can just kind of take a pill like they take maybe other medications.

And then also, I think because of the way it’s regulated, we have a very longitudinal relationship with our patients. They’re not going, like, externally to get their methadone. They come to see us for their scripts, which is kind of what we were doing during the pandemic.

Kevin Pho: Right. And can you walk my audience through your article, for those who haven’t read it, “With COVID-19, we have a unique opportunity and need to deregulate buprenorphine prescriptions”?

Megana Dwarakanath: Yeah. So I think one of the challenges that we noted during the pandemic was, because buprenorphine is such a highly regulated drug, many of the pharmacies were still requiring paper scripts for buprenorphine, and we couldn’t dispense more than, like, two weeks’ worth of medications. So every patient was followed up within about two weeks, and so it caused patients to need to come in more than they probably needed to for a medication that, for example, they were stable on.

It also was difficult because paper scripts would mean that there would be multiple people who the patients would need to see, first us, and then take it to a pharmacy, versus just having it e-prescribed and just having them be able to pick it up.

And then the third thing is there’s such a limit on the number of patients buprenorphine-certified providers can see. And SAMHSA, who kind of oversees a lot of these regulatory mechanisms, made some amends, because they kind of realized that it wasn’t sustainable in the current climate. But I think that they probably didn’t go far enough, which is that we probably don’t need waiver training, which is like eight hours of training, in order to get certified.

And I think, like, many of the barriers, such as having regulations on how long scripts can be prescribed or needing paper scripts in a lot of areas, would definitely reduce the barrier for people to go out and get their scripts. Because we were seeing that patients who, like, [inaudible] because of the pandemic, or were dealing with more psychiatric issues or mental health issues because of the pandemic, were less able to go do all the steps that it takes for them to get their medication, and they were also in a more vulnerable place to lapse.

Kevin Pho: So for patients whose buprenorphine supply is interrupted for whatever pandemic-affected reasons, what impact does it have on them?

Megana Dwarakanath: Well, they can definitely have withdrawal and cravings. Like, they’re on a medication that’s allowing them to function. And if a patient kind of gets to that point, a couple of things happen, and they did happen. One, the patient calls a dealer and says, “I’m, like, feeling really bad, and I probably need some heroin.” Two, they end up trying to obtain buprenorphine from the street.

We did have patients that got kind of desperate because they couldn’t get to the doctor fast enough or couldn’t really prescribe. And buprenorphine is very readily available on the black market because of all the regulations that come with prescribing it with providers. And so there are ways that buprenorphine can be kind of abused on the street, but sometimes patients are so desperate that the dealers become their PCP in that situation and are giving them the medication that they need.

Kevin Pho: Sure. Well, it doesn’t look like the pandemic is going to end any time soon. So you mentioned some of this earlier, but if you go into more detail, what are some of the solutions that you propose to address this issue?

Megana Dwarakanath: Yeah. So one is, I think we no longer need an eight-hour DATA waiver training in order to get physicians certified. I mean, I know that they’re trying to make the DATA waiver training a little bit easier, but that’s, like, a barrier that a lot of people don’t really want to sit down and do when they’re already very busy.

Two, I think buprenorphine is still on some of the highest cost-sharing tiers of insurance policy, so I think making that more readily available in terms of coverage would make access much, much easier.

Third, I think putting caps on the number of patients providers could prescribe buprenorphine to would be also very helpful, because there are limits on the number of prescriptions providers can even give, like total buprenorphine scripts. So that means that those providers are kind of even more bottlenecked right now in terms of the demand and the communities they work in. So we need to make it easier for people to prescribe buprenorphine, and not harder. Either not capping the number of prescriptions a provider can give, and then also increasing the number of patients a provider can see, especially in rural communities, would be super helpful.

Third, I think residents particularly are being underemployed in the kind of opioid use epidemic, but you need your own DEA waiver, like under your own name, not as a trainee, in order to give buprenorphine. So that’s a really easy thing to do, is to allow residents to issue their own scripts. Because what happens when there’s a change in the workforce, and let’s say an attending is getting pulled off of leave because they’re older, or they’re getting called to work in an ICU, is residents will be stepping up, and they might be managing outpatient clinics. And there are definitely more residents than attendings in kind of any program, and making it easier for them to prescribe would be very helpful.

Another thing would be for electronic scripts to be more readily available, so that, for example, if you can’t go into an office, which can be a pretty vulnerable experience if you’re older or at risk for COVID, you can still be assured that it will be at the pharmacy. And most states will have a national, or sorry, statewide database of how many scripts are issued and when a patient has come to refill it. So there really shouldn’t be too much abuse, especially when patients are staying in state more or less now.

And if we made it, like, even national, in terms of figuring out where scripts are coming from, which is what I hope all of this electronic medical record and paperless way medicine is going can do, then we should have no issues with making sure that there’s not double prescribing.

Kevin Pho: We’re talking to Megana Dwarakanath. She’s a pediatrician, and she wrote the KevinMD article “With COVID-19, we have a unique opportunity and need to deregulate buprenorphine prescriptions.” Megana, my last question. What is your take-home message to clinicians who may not have the substance abuse training that you have?

Megana Dwarakanath: So I would not say I’m an expert on it at all. I’m still kind of in training. But I think for residents, and for even attendings, in the pediatric population, I think we just all need to step up our game, because we’re kind of still letting that be in the realm of internal medicine and family medicine, to think about substance use disorder as an adult problem. And I think if we’re not thinking about it meaningfully as pediatricians, then we’re losing the biggest opportunity to intervene.

Some of the patients that have done really well on buprenorphine have been, like, 15, 16, and 17, and I think that’s where you want to treat people. My hope is that they’re not 50, 60, and 70 and still needing buprenorphine. So I think we just need to be more aware of it and advocate for more substance use disorder training in pediatric residencies in general.

Kevin Pho: Well, thank you so much for sharing your insight and wisdom, and thank you for being on the show.

Megana Dwarakanath: Thank you for having me.

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