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The end of SAMHSA’s “waivered prescriber” MAT requirement: a grant writer’s farewell

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.

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New grant wave forming for Medication Assisted Treatment (MAT)

A new grant wave is forming. An unexpected and shocking epidemic of heroin and prescription opioid addiction has erupted across America and the federal response is going to be a huge increase in funding for treatment and related services.

We’ve already seen signs of the grant wave in HRSA’s Substance Abuse Service Expansion program, which was designed to focus on “Medication-assisted Treatment in opioid use disorders.” Last week, the Obama Administration proposed a new $1 billion heroin treatment initiative involving pass-through grants to the states, which will in turn issue RFPs to local treatment providers, most of which will be nonprofits.

The new Obama initiative is to fund more medication-assisted treatment (MAT). Unlike the old methadone approach, MAT combines behavioral therapy with more modern medications to treat substance abuse disorders. While the Obama initiative is clearly aimed at treatment providers, peripheral grants are sure to become available for ancillary services like outreach, engagement, education and case management, most of which can be implemented by virtually any human services nonprofit.

Unlike many of President Obama’s proposals, the MAT grant initiative is likely to gain strong and quick bipartisan support in Congress, because vast stretches of rural America, as well as many suburbs and cities, are being overwhelmed by heroin, prescription opioid addiction, and concomitant ODs, often in the seemingly most unlikely of places. This includes over 400 ODs in New Hampshire in 2015. This bucolic state is not usually associated with a 22-year old woman overdosing in a squalid Nashua alley.

Listen to this heart-wrenching NRP story about how a middle aged and middle class New Hampshire makeup artist’s step daughter died. The makeup artist specializes in “painting” the presidential candidates that inundate NH every four years; she’s made-up everyone from Bernie Sanders to Mario Rubio this year. Each candidate has gotten an earful of the the addiction/OD crisis while captive in her chair.

In addition, almost every Democratic and Republican presidential candidate, with the possible exception of Hillary Clinton, seems to have been personally touched by the addiction and/or OD of a child, another relative, or a friend. It’s like Traffic writ large. Carly Fiorina and Chris Cristie regularly tell OD anecdotes as part of the their stump speeches, while Bernie and the now-out-of-the-race Rand Paul take a libertarian stand that prefers treatment over legal sanctions regarding substance abuse disorders.

When Bernie and Rand somehow agree on a major domestic policy issue, you know that the problem transcends politics. The US long-ago lost its 40-year “War on Drugs.” After over four decades of draconian law enforcement and incarceration that disproportionately affects communities of color, the net result is that heroin is actually cheaper than ever—the Washington Post reports that a bag of heroin costs less than a pack of cigarettes in much of America! High cigarette taxes are part of the reason, but heroin is not taxed. Taken together, these trends point to the need for nonprofits to be nimble enough to catch this cresting grant tsunami.