Getting meds: why does government make it so hard?

• Author: Satel, Sally
• Position: Special Report on Mental Health

Any of the 900,000 physicians in the country can--and often do--prescribe, at their own discretion, the kind of opioid painkillers whose abuse has led to a 300 percent spike in overdose deaths between 2001 and 2014. But if they want to prescribe medicines to help patients overcome opiate addiction, they face an array of government restrictions and systemic obstacles.

Take a medication called buprenorphine, approved by the FDA in 2002. Buprenorphine's profile has risen within the last few years. It suppresses drug cravings and quells withdrawal symptoms like muscle aches, sweating, anxiety, agitation, and diarrhea--also called "dope sickness." The drug is a less potent substitute for the classic opiate replacement drug, methadone, and has less of a potential for abuse. Some patients dose daily over weeks or months as a way to slowly detox from abused opiates. Others stay with buprenorphine for years.

In order to prescribe buprenorphine, Congress requires that doctors undergo special training and certification from the Substance Abuse and Mental Health Services Administration, or SAMHSA. The eight-hour course is not particularly onerous (I did it in three days at my computer, and it was an excellent refresher on opiate psychopharmacology). Nor is it expensive. Yet, according to SAMHSA, fewer than 32,000 doctors are certified. Worse, most doctors with the buprenorphine certification seldom administer the drug--40 percent of physicians allowed to prescribe it never do so, according to SAMHSA. Also, many doctors who prescribe buprenorphine don't accept insurance. In fact, physicians routinely find that patients who make appointments to begin buprenorphine treatment have already initiated the medication on their own after buying it on the street, an indicator of how hard it can be to find a doctor who prescribes it.

What's more, federal law limits certified doctors to treating only thirty patients at any given time during their first year of prescribing buprenorphine and a maximum of 100 patients thereafter. (If buprenorphine is prescribed by a doctor in a licensed clinic devoted to the treatment of opiate dependence, then there is no limit per doctor.) "Removing this barrier to buprenorphine is particularly critical in rural and underserved areas, where the growing need for [medication-assisted treatment] often outstrips the number of physicians licensed to supply it," according to the National Governors Association.

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