You could easily have missed it: in January, SAMHSA ended its waivered-prescriber requirement due to an obscure section of the recently passed Bipartisan Infrastructure Bill (BIL). Those of you who aren’t involved in the minutia of healthcare service provision and medication-assisted treatment (MAT) may read the preceding sentence and think: “What’s that about, and why does it matter?”* Until this year, the Drug Enforcement Agency (DEA) required that doctors and nurse practitioners (NPs) / physicians assistants (PAs) who prescribe buprenorphine—the key medication used to treat persons with what SAMHSA and HRSA like to call “opioid use disorder” (OUD)—get a special DEA waiver. This “waivered prescriber” requirement had the effect of severely limiting the number of doctors and other healthcare providers who could offer MAT. So you’d have situations where a doctor could prescribe potentially addictive opioid painkillers like oxycodone, but not the buprenorphine that is used to treat OUD. Welcome to the upside-down world of American healthcare.
This waivered-prescriber process always seemed baffling, and it turns out that I’m not the only person who wondered about what’s so special about Suboxone and similar drugs: back in 2015, for example, Scott Alexander wrote that any doctor should be able to prescribe it, and he observed that Suboxone, the “(generally safe) treatment for addiction[,] is more highly regulated than the (very dangerous) addictive drugs it is supposed to replace.” MAT works way better than non-medication efforts, although not perfectly.
Dr. Alexander** notes that:
Suboxone treatment isn’t perfect, and relapse is still a big problem, but it’s a heck of a lot better than most rehabs. Suboxone gives people their dose of opiate and mostly removes the biological half of addiction” and that “Some people stay on Suboxone forever and do just fine – it has few side effects and doesn’t interfere with functioning. Other people stay on it until they reach a point in their lives when they feel ready to come off, then taper down slowly under medical supervision, often with good success.
So maybe taking a daily dose of Suboxone isn’t ideal, but it’s a big improvement on OUD. How many people reading this have a daily dose of coffee, tea, Yerba Mate, or some other caffeinated substance? Sure, we can say that tea makes us more productive, but, compared with street and prescribed opioids, doesn’t Suboxone?
Probably the “waivered-prescriber” thing should have ended much sooner—but that’s far from the DEA or FDA’s most egregious blunder in recent times. Studies find that “FDA Deregulation Increases Safety and Innovation and Reduces Prices.” Maybe we should collectively think more seriously as a society about the costs of government paternalism. The supplement industry, while not exactly a shining star of excellence, works okay without the FDA. People who find FDA approval valuable could choose to only buy substances with FDA approval; those who are FDA skeptics could choose not to. Most supplement buyers don’t appear to care about FDA proof.
In the meantime, regarding OUD and MAT, sudden deaths from fentanyl remain high in NYC—and fentanyl is often accidentally or intentionally mixed with non-opioid drugs like cocaine. This could be a legalization or decriminalization argument: black-market items rarely follow Good Manufacturing Practices (GMP).
Oh yeah, and it looks like naltrexone curbs binge drinking, apart from severe alcoholics. Estimates vary but most find that around 10% of Americans have an alcohol problem. There are also indications that semaglutide reduces the appeal of alcohol (here is one clinical trial examining that subject). In the last links post, we mentioned a monoclonal antibody that reduces amphetamine effectiveness. Although none of the anti-addiction medications s mentioned in this post are likely to alone solve concomitant addiction crises, they’re likely to help. We as a society have at least 50 years of experience in trying to resolve addiction crises without extensive medication-assisted treatment, and the results are apparent. The “War on Drugs” hasn’t worked. Talk therapy and 12-Step programs are better than nothing but don’t work all that well on their own. I guess we’re now at the stage where we’re trying MAT more seriously, and soon we’ll be at the stage where we try psychedelic therapy (sample clinical trial, but there are many others). Trying something new when the old isn’t working makes sense at a personal and a societal level.
* If you or anyone you know has struggled with what’s now referred to as “opioid use disorder,” it matters a lot.
* He’s a psychiatrist.