Our Experts Weigh in on Biden Administration’s Move to Ease Prescribing Requirements for Buprenorphine

Dwight Hurst, CMHC: Hey, everybody, welcome back to a podcast to answer your questions on addiction, recovery and mental health by Waismann Method Opioid Treatment Specialists and Rapid Detox Center. I’m your co-host, Dwight Hurst, joined, as always, by Clare Waismann and David Livingston. Well, we’re trending today, as in we’re talking about some real current events that are happening in the field in the world of addiction treatment. So we’re starting out with I’m going to read the headline from an NPR article by Brian Mann where he’s summarizing and talking about this breaking news. It’s called As Opioid Death Surge, Biden’s Team Moves to make buprenorphine treatment mainstream. Buprenorphine? Did I say that right?

Clare Waismann, RAS/SUDCC: Buprenorphine

Dwight Hurst, CMHC: Buprenorphine. So to make buprenorphine treatment mainstream and it’s talking about an announcement that’s just been made within the last few days, I think, if not the last week, talking about how federal guidelines are changing with treatments and some real, real big news. And we’re going to get into that of what both of that means and how you feel about it. So maybe good for those who don’t know buprenorphine is how could we nutshell that to let people know a little bit what that is and what this change represents?

Clare Waismann, RAS/SUDCC: Ok, so buprenorphine is a drug that contains an agonist and an antagonist, so it’s an opioid medication that is used to control opioid use. So in other words, it’s not a detoxification, but patients that are using heroin, patients that are using high doses of prescription pain opioids, they use buprenorphine drugs in order to kind of regulate what they’re taking and more importantly, you know, limiting the risk of overdosing. So that is, you know, the goal of the buprenorphine is maintaining the patient without withdrawing or craving for their chosen opioids, that is out of control.

Dwight Hurst, CMHC: And I’m trying to remember, is that in use it at Waismann Method? Is that used in care? Is it one of those?

Clare Waismann, RAS/SUDCC: No, we do not.

Dwight Hurst, CMHC: You guys don’t use it at all, right?

Clare Waismann, RAS/SUDCC: We do not use any maintenance opioids. We actually detox patients from them. So buprenorphine-based drugs like Suboxone is on the first three drugs we detox most of our patients from because they are long-acting drugs and the withdrawal can be quite expensive.

Dwight Hurst, CMHC: So you’ll sometimes work with people who are on if I’m not mistaken, naltrexone, which is a whole different thing, right?

Clare Waismann, RAS/SUDCC: No, no. Naltrexone is an antagonist, is not an opioid at all. So it is the complete opposite – agonist is an opioid because it attaches to the receptors, right? Antagonist is the opposite of an opioid, naltrexone is an antagonist, has no opioids, has no addictive abilities, and it causes zero withdrawal.

Dwight Hurst, CMHC: So that’s important to recognize the difference between those two medical approaches. Yeah.

Clare Waismann, RAS/SUDCC: Right, so naltrexone is a drug that is used once the patient is off opioids completely. And it is used to eliminate cravings because it blocks the receptor site, but again, it’s not a drug that can be addictive or has any withdrawal symptoms if the patient decides to stop.

Dwight Hurst, CMHC: And that’s really that. And that’s I mean, I’m sure, you know, that’s going to get into some of the feelings that that this brings up. But that’s an important difference for people to recognize right up front. So it’s not all the same thing when you hear someone say, oh, it’s medicine used to treat addiction. Yeah, but they’re very, very, very different. Right. Types of medicines. Gotcha.

Clare Waismann, RAS/SUDCC: Yeah. Well, because addiction that there are so many different factors that, you know, it becomes addiction. I mean, from the physiological part of it to the emotional part of it. I mean, it’s not just one facet.

Dwight Hurst, CMHC: So let’s maybe then talk about what this change represents, one of the things that I see from the article is that they’re they’re releasing some guidelines that are relaxing, some guidelines that some trainings that were required before practitioners could prescribe buprenorphine.

Clare Waismann, RAS/SUDCC: Correct. They’re lifting guidelines that we will allow health workers and not just doctors to prescribe buprenorphine-based drugs, what allows rural areas that do not have the right amount of physicians to be able to prescribe more of this drug, hoping to eliminate the overdose issue. So that’s the pro. The con is you have a number of health workers without training because that’s something else that they are removing, is the training necessary to prescribe these drugs? What can cause a tremendous amount of issues? So. Again, you know, it’s we got to put it on the scale, the good and the bad, and then you have for me, the more important issue, are we putting another Band-Aid in a sore that continues to grow? So the issue here is, you know, not the overdoses is why are there so many overdoses? Why are people using, you know, so much drugs? Why have the drugs become so much more dangerous than they used to be? So that’s what I’m trying to say. I think that’s the very one-sided solution to a multifaceted problem.

Dwight Hurst, CMHC: And that’s something that comes up a lot with any kind of nuanced problem. But I think we’ve discovered this and touched on this on the show before, that any type of a nuance or trying to take a multifaceted approach to solve a big problem is, well, it just doesn’t happen as much as we would hope that it would. You know?

Clare Waismann, RAS/SUDCC: Right. Because we’re using we’re hoping for easy miracle solutions. That sounds very good. I mean, I think anybody working for a solution of a problem like the opioid crisis, you know, it’s a plus. But we have to make sure that people are educated and in what the treatment is, what is supposed to do its risks and its benefits and any treatment.

Dwight Hurst, CMHC: I don’t think I don’t know if I’ve told this or touched on this in the bag as before, but I remember working in a place once where there was a really big morale problem. It was a pretty bad culture that had grown out of it. It was managed health care and a lot of people were burned out. And one of the administrators decided that we were going to start having brown bag lunches once a month, that everybody would gather together and enjoy each other’s company. But it was not quite mandatory, but it was expected that you’d be there. You had to use your own lunch break. You had to bring your own food. And you also were expected to, you know, be careful about not getting back to work too late after. So it didn’t work, to shorten the story. And it was this one chop to knock down a huge big tree. Right. And it sounds like that’s one of the major concerns, is it’s not addressing yet, not addressing all the facets of the problem.

Clare Waismann, RAS/SUDCC: Yeah, I think I go back to the same place every time. I wish they, the administration would put 10 percent of their pharmaceutical efforts into mental health care. And I think we would be solving a lot more problems because now we’re dealing with the real issue is why are we suffering so much? Why are people hurting so much? You know, is it an opioid crisis or is a distress and emotional distress crisis? No. Because, again, if we if they don’t have the opiates, they will look for the alcohol or they will look for something else. They’re trying to treat those emotions they cannot handle. And if we offer them the mental health care they needed, then we wouldn’t be in the situation in the first place.

David Livingston, LMFT: There are benefits to Buprenorphine, particularly with people who are at high risk of overdosing, who, for one reason or another are at risk. And you’re really trying to do a process of harm reduction. And I think Suboxone is one of those medications that can be useful for a certain group of people in terms of harm reduction. And I think one of the things that happens when you’re treating people very often is that the goal is to do the harm reduction and so doing, and because of that, there’s a that that’s the initial impetus. And so the difficulty of getting also in the fact that it’s such a long-acting opioid and stays on, it’s very, very difficult to get off of. Sometimes people can, but very often they can’t because it goes on. The detox process goes on so long it’s rarely talked about upfront. And there’s no really the idea that you can titrate down is true. You can titrate way down to the very end goes on for a long, long time. It’s very hard on people. So there’s and I don’t think there’s a big educational, we need to educate, particularly up front, because the desire is to get people onto the medication and out of harm.

David Livingston, LMFT: And I can see the rationale for that. I tend to think that it’s better to tell people as much as possible and some people don’t do well, and we’ve seen a lot of people who’ve been on Buprenorphine and have not done that well. They haven’t felt well on it. You know, like any medication. Some people are fine on it, some people aren’t and they don’t respond well to it. So it’s complex. I understand the reasoning behind it to some degree. I do think what Clare is saying as well in terms of, you know, really trying to create a different standard of care where there’s really a process of trying to help people in the prolonged ways is another approach, because you often see people go on medications and then it becomes kind of on and off this or that, and some people can do well. So it’s complex. There isn’t an easy answer, but there should be a lot of evaluation upfront and a lot of education upfront, as is my belief.

Dwight Hurst, CMHC: And that’s often and this is.

Clare Waismann, RAS/SUDCC: Exactly. And that is one of my major concerns with the new guidelines put in place right now is because they are eliminating a lot of that education for health care workers and dealing with a population that is not just physically there, but emotionally as well. So when you remove the education needed in order to treat these people, you know, there is going to be a lot of mishaps. And I don’t think people can afford any more mishaps on the treatment of their health.

Dwight Hurst, CMHC: Well, we’ve seen quite an uptick in overdose deaths and also in drug use over the pandemic, right?

Clare Waismann, RAS/SUDCC: Right. What was to be expected. And when you’re talking about opioids, per se, tick on overdoses is due to fentanyl. Most people that call us today, regardless of what they were taking before. And David, you probably can attest to that, they’re actually taking fentanyl. Fentanyl has been introduced in every possible drug being sold out there from Xanax to Heroin, to prescription pills, they’re buying prescription, so they could be oxycodone, it could be Norco, could be whatever Percocet, truth is it is fentanyl. So because fentanyl is introduced to all these drugs, the risk, level of risk of overdose have multiplied. And that’s where you’re seeing all these overdoses and they don’t expect it to be fentanyl. Actually, a lot of the patients right now, believe it or not, they have a little test kit with them when they buy drugs in the street to make sure they know the amount of fentanyl in it.

Dwight Hurst, CMHC: Oh, really?

Clare Waismann, RAS/SUDCC: Oh, yeah. That’s how crazy it has gotten. The issue with this, the crisis, there’s so many facets to it that where we have to protect our citizens from the lack of mental health to do, you know, fentanyl just flooding every corner of our society. And one will being locked up, absolutely…

Dwight Hurst, CMHC: One of the things that I know we I know we talked about it and some people talked about it, but I didn’t hear it talked about enough during the pandemic. And people not being able to access people were frankly, they weren’t able to access health care sometimes for things that were not a crisis. And they also sometimes weren’t able to access drug use as much either. So there was a lot of withdrawals from alcohol use and opiate use. And what we’re talking about is a medication that does cause withdrawal. And so I can see some of the same problems potentially. If you can’t get access to refill a prescription for this, perhaps if there is another uptick in, you know, in health care needs and a mutation of covid, I mean, not to be doom and gloom, but I could see that being a problem as well.

Clare Waismann, RAS/SUDCC: And there is something else, too. One of the biggest complaints, when I speak to patients that did take any buprenorphine drug, is they will say, oh, I’m allergic to buprenorphine. And I say, what does that mean? Oh, when I took it, I was very, very sick. That means they take in too early because there has to be, you know, a time lapse between the last time they use and opioids to take buprenorphine or it will send them into an instant withdraw. The issue with that becomes now you’re dealing with fentanyl. That is a much stronger drug that can last in their system a lot longer. Now, if trained doctors are having a hard time figuring out when to give and what dosage to give, buprenorphine, imagine untrained people get understand once opiate patients feel desperate, especially feeling a withdrawal, what what do they tend to do? The only thing they know that makes them feel well. Now you have a drug like buprenorphine that is an agonist and an antagonist and you try to use opiates so you feel better from the side effects of buprenorphine. I mean, it’s just going to be a nightmare. I think if money should be spent, should be in more training, not not less.

David Livingston, LMFT: I think what happens is people are put on buprenorphine and I’m not even sure I’m seeing it correctly. Yeah, thank you.

Dwight Hurst, CMHC: We have Clare on the line. She knows how to say, I always miss it

Clare Waismann, RAS/SUDCC: And I’m the only immigrant here.

David Livingston, LMFT: And one of the things I see, I see patients who come through and I enjoy listening to their stories and having worked with, you know, hundreds and hundreds of people coming off of Suboxone, you’ll hear different stories, like, I didn’t know I was getting on a drug that was going to be harder to detox. I was on you know, I had a back surgery and and then I was put on this, told that it was a treatment or it was, you know, without any education or knowing that it was how hard it would be to get off of. And so it’s it can there’s often, you know, which is very different than if somebody is at risk, you know, for overdosing or something like that, you know, and sometimes people will be at risk for that and put on it for a number of years. And then they’re like, I got to get off that. I can’t get off it. So, you know, we see a lot of people coming through who are just done with it all. They don’t want to be on it. They don’t feel good on it. And whether it’s, you know, in the beginning or eventually, very often people stop feeling good on Buprenorphine. And say, you know, it’s it tends to sort of eventually the body can reject it. And I know that’s not necessary when people are in danger immediately. That’s not a concern. And I can I can appreciate that because certainly trying to curtail the overdosing makes more sense than anything.

Dwight Hurst, CMHC: But not everybody is a candidate for it. It is not depending on what people are really needing. And so there really needs to be an evaluation, a really sincere evaluation then rather than just pushing everybody to it because everyone’s in danger of overdosing. Everybody isn’t in danger, as some people are. And you really can if you really listen to them and if you’re not pushing them one direction or another, they’re generally telling you what’s going on. So that’s that’s a concern because I think actually people can later get into more trouble. Like Clare was saying, when you can’t get off of it and then you’re not sure what to do and when people are in that state or going through prolonged withdrawals, they go into a fight or flight reflex at a certain point and they, you know, make bad decisions and often go back on opioids or things like that. I’ve heard that many, many times. So it’s a complex issue. I don’t know. I don’t think it’s being addressed at all in the way we’re talking about it or even talked about in the way we are. So, again, I understand some of the reasons why you don’t want people dying and you want to you know, that’s the major focus. But it’s more complex by far.

Clare Waismann, RAS/SUDCC: An example of what David is talking about. Like, so this week we had this guy calling us. He has cardiac issues. He has had a number of different surgeries. He is on blood-thinners and he is over two hundred and fifty pounds. He was taking four Percocets a day. His doctor put him on sixteen milligrams of Suboxone a day. I can’t even tell you what the difference between Percocet and six milligrams of Suboxone is. It is the same as if he came here, and I’m going to try to give you an idea saying that he was drinking two beers a day and I gave him a bottle of vodka to have a day. So a patient that normally we would accept and put him in a hospital and detox while controlling his heart rate blood pressure, make sure a specialist was there to make sure there was no stress, to get him off four Percocets quite easily, we had to deny treatment because of the levels of the amount he is in. And what a withdrawal. for 16 milligrams of Suboxone will be in his body wouldn’t be able to take it. And so what they have done of this guy is get a patient that was absolutely treatable to a patient that now has to start titrating and then his blood pressure go high and his heart rate gets higher. So he’s actually at much more health risk than he was before. And nobody wants to touch him.

Dwight Hurst, CMHC: It’s got to be frustrating for one thing, but not just for the treatment professionals in this case, if you’d love to be able to help him. And that’s frustrating. But then it’s got to be for him that’s intimidating. And, you know, in that case, if I’m in his shoes, I’m needing to do something that is probably very difficult at his stage, which is to do a lot of self-management before getting into the heavier treatment.

Clare Waismann, RAS/SUDCC: Correct. So right now, he needs to titrate down and this can take years to do with, you know, again, having somebody managing his vitals throughout. And oh, and another side effect of Suboxone that a lot of patients complain about is depression, so he’s feeling extremely depressed and hopeless. And again, this was a patient that if you called us and he was taking four Percocets, you know, in a few days in the hospital, we could get him through that withdrawal safely. So that’s and that is prescribed by a physician. That doesn’t have enough knowledge to be prescribing this drug, and that is a physician that has gone through the training to prescribe this drug. Now imagine numerous, you know, several health care workers without any training. So that’s a concern.

Dwight Hurst, CMHC: So that brings us to a question I have, which, you know, we talk about the things that maybe should be focused on. Right. And I’m interested to see what you guys think. If there was a slice of resources that we could take and throw at mental health or training or different things like that, where would you allocate it?

Clare Waismann, RAS/SUDCC: I think education, mental health. I mean, we’re always chasing the issue once the issue has become a crisis, allocating our resources to prevention allows us to treat the people that are already suffering without having the income of new ones, you know, at a level that we can never handle.

Dwight Hurst, CMHC: So you say proactively, like like more for, well, proactive. I mean, we don’t really funnel people into mental health treatment until there’s a crisis, as you put it. It’s all one of the biggest critiques of mental health treatment is that it is pathology based. Right. And you see a movement to be more proactive in the sense of saying psychological health is just health. Right. And that line of thinking is new and is different in a way from saying, well, you know, when you have an event, come to the hospital and we’ll try to stabilize you so that you’ll be literally safe to your physical safety when we let you out in a few days instead of saying, like, boy, everybody should be getting education and being screened for it just along with cholesterol or blood pressure, any of those measures that we would usually take?

Clare Waismann, RAS/SUDCC: Correct.

David Livingston, LMFT: I think it’s very unusual that any people could have any sort of real treatment. In fact, I would say that the reason Suboxone is kind of being used because nobody is really getting any significant treatment. So to get a significant treatment, you have to be established with somebody who you’re connected with, who you feel like you have confidence in, is helping you understand what’s going on. And there’s an established relationship that lasts over time where there is a desire to, you know, rework and deal with some of the things that are limiting you and your life or causing you to cope through, you know, opioids or other things like that and give it in helping give you time to, you know, for for the brain. So there’s our emotional life and our personality and, you know, what’s going on situationally in our life. And then there’s how the brain is sort of coping with coming off of an opioid. And all of a sudden, so there’s a number of factors that and rarely do people get established in a process and with a therapist or that is going to really work with them to kind of work things, things out over time.

David Livingston, LMFT: And so it’s not it’s unusual that you will see that. I think it’s and I think it’s kind of what you’re speaking to, Clare, and certainly Dwight. So I think people can test potentially when that’s happening. And that’s not like it’s not like there’s a fix-all to anything. But I think it gives people the best chance to really get to know themselves, understand themselves, and then have more options to creatively sort of deal with their lives. And, you know, so there’s a million reasons that’s not happening. Some of it’s financial. Some of it is like like you were saying, although it’s really not true anymore, that, you know, it’s pathology-based. It’s really not pathology-based. The idea of psychotherapy, it’s really just it’s really more of you know, based on humanity. It’s just everybody’s going through different things. It’s just it’s hard to be alive. It’s hard to make your way in the world. It’s hard to juggle work and relationships and family. All these things are hard. So I think what happens when you get into treatment is it feels like you have an ally to sort of work those things out.

Dwight Hurst, CMHC: And it is. You know something? I hear what you’re saying. I think that sometimes people go through that crisis in order to access. But, you know, you’re right, once they get into therapy, I think the approach has become way more focused on the person. I will say too, I do see some positive leanings in individual and group thinking with people. And I remember going to a career day a couple of years ago at my kids’ school two of my two older kids. And when I gave a little presentation about “Oh, what do you do for a living?” “I’m a therapist”, and in all the groups that came through these little groups of kids, somebody in the group said, I have a therapist, I have ADHD. You know, when kids like, well, I have autism, here’s what that means. And they weren’t ashamed of it. And so I think one of the benefits we see with the up and coming generation is that there is a little bit more of that. And some of that goes to good decisions by parents to proactively reach for that. But so I think you’re right, there is some reasons to be hopeful. But are we seeing that on a grand scale to allocate resources to make sure that that’s happening, to educate the public? And I think that’s exactly, those are great things to be saying on our wish list of what would happen.

David Livingston, LMFT: That’s right, that’s right, it’s also hard, right? What is the what is that the Greek word? “Argo” means to be in the arena and it also means agony. So to go into therapy is a type of agony because you’re in the arena, you’re in this area where you’re trying to get there you become more self-conscious. You’re talking about yourself. And there’s somebody who’s witnessing. And so there’s the impediment to sort of do that, which is why often symptoms sort of dictate people getting into therapy because the symptoms get bad enough that the agony is there and then they want help. But the truth of it is once you’re in it and if it’s going well and you start to titrate and understand, it ends up just the opposite, right, where it actually becomes a place of relief and you begin to feel, you know, what healthy dependency can be. And I would say that that dealing with health and understanding healthy dependency may be one of the most confusing things culturally that we have.

Clare Waismann, RAS/SUDCC: I would just like to finish saying that there is no right and wrong when we are treating people with responsibility and respect. But we need to stop focusing on the effects of the condition and start looking at the patient in front of us, you know, there often unseen because we concentrate so much on the side effects, the elements that we can see, we become blind to what is not in front of us. People want to be hurt sometimes if they can’t afford to go to psychotherapy every week, at least the person that is treating them. Before you decide what treatment you will give them, hear them out, find out where they are, where they want to be, where they should be, you know, allow them, allow them to speak to you, allow them to feel like a human being, and then go from there, make your best evaluation, the best possible treatment option without, you know, preset protocols. That is so important.

Dwight Hurst, CMHC: Thank you, everyone, for joining us today for a discussion. As always, we love fielding your questions about opioid dependence, about recovery, mental health, addiction. This is a program that is really out here to help people, to make good decisions and to feel some hope around these very, very challenging issues. Speaking of that, if you have questions that you would like to share with us, please reach out to us, send us an email at info@opiates.com, or hit us up on Twitter @opiates. Anything that you’d like to share with us is something that we can definitely use in the creation of the program. And we also just love to connect with people who are listening. This podcast is, of course, a production of the Waismann Method Advanced Treatment for opioid dependence and produced by Popped Collar Productions. As always, our music is the song Medical by Clean Mind Sounds. The show, hosted by Clare Waismann, a registered addiction specialist, substance use disorders certified counselor and also the founder of Waismann Method and Domus Retreat. And by David Livingston, licensed marriage and family therapist and clinical director at Domus Retreat. We just want to remind all of you listening again to keep asking questions, because when you ask questions, you’re on the track to find answers. And if we can find answers, then we can find hope.