Opioid overdose is now responsible for one in five deaths among young adults—an astonishing proportion, according to new data from the American Medical Association. These losses aren’t inevitable: We actually have two medications, which, if made widely available, could cut opioid-related mortality by 50 percent or more.
Unfortunately, while doctors and activists are fighting to expand access to buprenorphine and methadone to people in need, the Department of Justice (DOJ) seems determined to do the opposite—and is raiding and criminally investigating some of the few physicians who are actually willing to prescribe these drugs.
Research shows that this medication reduces both relapse rates and overdose death rates among people who are addicted—and it does so regardless of whether people are required to attend counseling. It even cuts risk when people continue to take other drugs.
As a result, cracking down on buprenorphine prescribers during a fentanyl epidemic is like locking up AIDS doctors during an HIV outbreak: It simply means more people will die.
Last month, Washington, DC-based health and corporate law firm DCBA released a letter sent to President Donald Trump regarding these investigations. DCBA says it represents a group of medical professionals who are so worried about possible DOJ retribution against their addiction treatment programs that they prefer to remain anonymous. And the doctors are terrified for their patients, whose lives are at risk from overdose from even brief interruptions in care.
In the last two years, at least several dozen prescribers of addiction medications have been targeted by the Drug Enforcement Administration (DEA) and other law enforcement agencies in Pennsylvania, Massachusetts, Indiana, and Kentucky, among others. Attorney General Jeff Sessions has recently begun a “surge” in similar actions against doctors and pharmacists. The law firm’s letter calls on Trump to fire Sessions, stop the raids, and ensure that medical boards OK such investigations before criminal procedures are set in motion.
The letter comes in the wake of FBI raids on two prominent addiction doctors. One of them, Stuart Gitlow, is a recent past president of the American Society for Addiction Medicine (ASAM), which is the leading specialty society in the area. Gitlow prescribes buprenorphine, and his home and office were raided in March, leaving those who were supposed to receive prescriptions that day to fend for themselves. As one patient, Kimberly Bussey, who says she witnessed the raid, put it on Facebook, “Sending a person out like this can trigger relapse for them. This isn't right.” (Gitlow told the local newspaper that he has “no idea” why he was raided).
ASAM literally sets medical standards for addiction treatment. Gitlow himself has also run for state representative and mayor of his town, Woonsocket, Rhode Island, as a Democrat. He’s not exactly the fly-by-night-type one thinks of as a likely pill-mill operator.
The problem is that law enforcement has long been skeptical of using methadone and buprenorphine—opioid medications that can cause a high in people who are not tolerant to them—to treat addiction. When they see street use of these drugs, they imagine that treatment has failed, rather than recognizing, as the research shows, that people with addiction prefer heroin or other similar opioids (like OxyContin) and that, overwhelmingly, “diverted” buprenorphine is used to avoid withdrawal, not to get high.
Basically, diversion occurs when it’s easier to get these drugs from dealers than from doctors—and so, ironically, making doctors less likely to prescribe them will make that problem worse.
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While any human being can go off the rails, it seems unlikely that a doctor who has worked much of his life fighting for better addiction treatment would suddenly decide to throw it all away and become a drug dealer. And equally odd: another target of recent raids was a Tennessee physician who presided over that state’s addiction medicine society and helped write the state’s prescribing standards.
Although unable to comment on these cases specifically, Sarah Wakeman, medical director of the substance use disorder initiative at Massachusetts General Hospital and assistant professor of medicine at Harvard Medical School, says that “raiding, investigating, and prosecuting physicians and other prescribers providing buprenorphine treatment is incredibly harmful and counter-productive.”
She notes that only 4 percent of doctors have even taken the required training to prescribe this medication and, even then, most of them don’t actually prescribe it. Indeed, less than one tenth of people who receive specialized treatment for opioid addiction receive buprenorphine.
That’s because, like other Americans, many doctors hate and fear people with opioid addiction and prefer to avoid treating them if possible. And, of course, doctors are even less likely to step up and help if it will put their own careers at risk. “One of the many barriers that keeps doctors from being willing to take this on is a fear of these types of investigations,” Wakeman says. “We need to be incentivizing physicians to provide this lifesaving treatment, not making them fearful.”
“The current overdose crisis is an indictment of our system for regulating drugs,” says Leo Beletsky, associate professor of law and health sciences at Northeastern University. “We overprescribe prescription analgesics while also vastly under-prescribing medications to help patients get a handle on their addictions.”
In fact, while addiction medication prescribing requires doctors to undergo additional training and to limit the number of patients they treat, any MD can prescribe even the most dangerous opioids like fentanyl to any number of patients at all, without such barriers.
While noting that he cannot comment on any particular case, Melvin Patterson of the DEA says in a statement to Tonic that his agency uses many different tools to fight drug diversion, including removing DEA licenses to prescribe controlled substances. “While only a minute fraction of the more than 1.7 million individuals with DEA registrations are involved with this type of activity, we work every day to identify the sources of the diverted prescription drugs,” adding that “during the past seven years, we have removed approximately 900 registrations annually.”
Shruti Kulkarni, an associate at DCBA, says the letter to the president was written after some prescribers became concerned that they were being investigated based solely on the amount of addiction medication prescribed, rather than because there was genuine criminal evidence against them.
Numbers alone can’t determine whether a crime has been committed: The “normal” amount of opioid prescribing for a physician treating pain or addiction will inevitably be much higher than the average for all doctors or the typical amount in most other specialties.
Consequently, in 2009, the National Association of Attorneys General and the Federation of State Medical Boards released a recommendation suggesting that criminal investigators consult the state medical board for advice when it is not clear whether a doctor is outside the bounds of appropriate care. The DCBA wants such consultation to be required.
“In terms of having a chilling effect, this is bad,” says Margaret Jarvis, a psychiatrist and the current vice president of ASAM, who’s also been involved in overseeing the group’s guidelines for care. She adds, “We’re not in a position to know the details of any particular case where this has occurred, but we’ve obviously got concerns that people who we think might be doing a very good job are getting caught up in this.”
In fact, addiction advocates have literally spent years trying to convince doctors that they can safely treat opioid addiction with buprenorphine and that doing so won’t put them in legal jeopardy or force them into an unpleasant and hopeless area of medical practice. “Many of us who do addiction medicine love what we do and we wouldn’t want to do anything else,” Jarvis says. “But we are very few and far between and we need support and help from other providers.”
When the streets are flooded with high-potency, illegally-manufactured fentanyls that are unpredictably mixed into heroin, cracking down on buprenorphine providers is the last measure anyone should take.
Yes, it’s easier to find “drug dealers with a pen” if you simply define dealing as prescribing more than a certain amount—and busting doctors is certainly less risky for officers than going after violent cartel kingpins who run the fentanyl trade. And, yes, you can rack up big numbers of busts by targeting docs, who, unlike dealers, list their addresses and contact information in public records. But isn’t the point to actually reduce the toll of addiction and save lives?
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