By Melba Newsome
About a decade ago, Blake Fagan vowed he would never write a prescription for Suboxone, a combination of buprenorphine and naloxone used to curb the opioid craving. The Asheville family physician had seen the ravages of the opioid crisis up close and couldn’t imagine aiding and abetting it which he believed medication-assisted therapy would do.
“I said, you’re just substituting one addiction for another,” said Fagan, chief education officer at UNC Health Sciences at the Mountain Area Health Education Center in Asheville.
These days, Fagan not only prescribes Suboxone (the generic name is buprenorphine), he sees that primary care doctors in residency programs in North Carolina are qualified to prescribe the drug, too. He views this as another spoke in the wheel of addiction treatment.
Fagan’s thinking changed after a patient was brought into the emergency room after an overdose and later died. Years earlier, he had delivered the young woman’s two children.
“It just broke my heart,” he says. “I realized that this medicine could have saved her life. That’s what’s been driving me.”
Preliminary 2020 data shows the coronavirus pandemic exacerbated North Carolina’s opioid crisis, increasing overdose-related ER visits by 23 percent. But Suboxone, a drug that can help, is still too hard to get.
Overdose crisis forces a change in prescribing
Fortunately, the one upside to the epidemic of overdose deaths is a slew of new initiatives and additional funding to improve the way physicians, physician assistants, nurse practitioners and other health care providers prevent, identify, treat and support the recovery of their patients who have, or are at risk of developing, an opioid use dependency.
Much of the focus has been on educational outreach to health care providers about safer opioid-prescribing practices. But many addiction medicine specialists believe the greatest opportunity to curb opioid overdoses lies in expanding access to medication assisted treatment.
Most training efforts have focused on practicing primary care providers, but these efforts have fallen short in North Carolina and elsewhere. North Carolina is one of 11 states where buprenorphine prescribers per opioid death rates are well below the national average. Nationally, fewer than 4 percent of licensed physicians are approved to prescribe buprenorphine for opioid use disorder, and roughly half of all counties lack a buprenorphine-waivered physician.
Prioritizing medication assisted therapy
When Mandy Cohen first came in as secretary of the North Carolina Department of Health and Human Services, Fagan says she made the opioid crisis a big priority.
“Dr Cohen said ‘I want our state to be progressive. What are some of the progressive things around opiates we need to do?’” he recalls.
To prescribe Suboxone, doctors must complete an eight-hour training program and get a waiver from the federal Substance Abuse and Mental Health Services Administration (SAMHSA) to prescribe buprenorphine for addiction but not for pain. Physician assistants and nurse practitioners require 24 hours to get the waiver that enables them to provide opioid treatment with buprenorphine in an office-based setting.
One of the things Fagan and others suggested was the need to train more providers in the state to write prescriptions for buprenorphine. A few days later, Fagan got a call from DHHS asking how MAHEC could help more doctors get waivered to prescribe the drug.
“We said, we need to train the residents that are actually in training, the majority who will practice across the state,” he said.
Learn more about practitioner buprenorphine training requirements.
- Physician Buprenorphine Waiver Training 8-hour training
- Nurses Buprenorphine Waiver Training (NPs, CNSs, CRNAs, CNMs) – 24-hour training
- Physician Assistant Buprenorphine Waiver Training – 24-hour training
Training residents
North Carolina first released its Opioid Action Plan in June 2017 and has updated it twice since — in June 2019 and May 2021. The Opioid Action Plan addresses the provider shortage through coordinated residency training in family medicine, internal medicine, ob gyn, psychiatry, emergency medicine and pediatrics, the six first line residencies.
So far, over 1,000 residents in over 50 residencies in the state have been trained. Since there are new residents each year, Fagan and MAHEC devised a training plan for the faculty at each of these programs so that this education is ensconced into their training.
According to DHHS, since the Opioid Action Plan was launched, dispensing opioids as a pain reliever has decreased by 34 percent while at the same time prescriptions for drugs used to treat opioid use disorders increased by 33 percent. In addition, opioid use disorder treatment specifically for uninsured and Medicaid beneficiaries has gone up by 48 percent.
Looking for a health care provider who prescribes Suboxone/ buprenorphine? Click here.
Training medical school students
The Governor’s Institute, a Raleigh nonprofit focused on improving how the health care professions prevent, identify and treat substance use disorders, was awarded the three-year SAMHSA grant to expand medication-assisted therapy by training medical school students, physician assistants and nurse practitioners.
According to executive director and program director Sara McEwen, the schools of medicine at UNC Chapel Hill, East Carolina University, Wake Forest University and Campbell University have all integrated eight hours of opioid use disorder training into their standard medical school curriculum. Collectively, they churn out approximately 545 physicians each year who have the option to apply for their waiver once they receive their prescribing authorization number from the federal Drug Enforcement Administration.
Participants in seven of the state’s nurse practitioner programs and one of the physician assistant programs have integrated a mandatory 24-hour training course into their curricula. In North Carolina, waivered Advanced Practice Providers, or APPs, cannot prescribe buprenorphine unless their physician supervisors are also waivered. The Governor’s Institute is offering professional mentoring to encourage physicians who are on the fence to take the training.
The Institute’s SAMHSA training grant runs out in September but, given the program’s success, fingers are crossed that the funding will be renewed.
“We are hoping to get a no-cost extension so that we can further build out the clinical exposure/faculty development components which were affected by COVID,” says McEwen. “We have also applied for funding to work with several of the APP schools next year.”
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I was prescribed Subutex a few years ago for my back pain which is a pain level of 9!
From a Terrible Car Accident where I broke my L1,2,3 Vertrbras, my left arm, facial fractures, andwas Life lifted to ChapelHill Nc. The Dr a Psychiatrist that prescribed me the Subutex bk in 20l6 or 17? never told me that I could not take my Anxiety medication along with my Subutex, so later on I had to change Drs, because this Dr moved. And that’s when I had to make the choice between the 2 meds Subutex or Klonopin. I don’t take Klonopin every day, only on a , “As needed” basis to control my Anxiety and panic disorders. So bk in December I started to taper myself off the Subutex going from 2 8mgs a day down to a quarter every other day.,but I hated it because the Subutex actually managed my back pain really well. But I had to make the decision on which one was more important and my Anxiety and Panic Attacks have gotten worse since the Pandemic started and from recently losing my Mother to Covid Pneumonia. So I stopped the Subutex Dr at the end of Jan-21 ,and then started back on my Anxiety medication, but I’m still dealing with severe back problems and Subutex did help. The ” PROBLEM ” I’m facing now is since I was prescribed 2 of the 8mgs of Subutex a day I never told the Dr I had Already started to wean myself off of the Subutex because I was afraid of the Stories I’d heard about going through Subutex Withdrawals & I was saving the extras so I wouldn’t have to go through Subutex Withdrawals , but that Dr figured it out since I was only coming in long after I should have been out of Subutex, so therefore he wanted me to daily dose but I refused because I thought I would be fine on a Quarter every other day as I’ve been doing for quite some time now. I even checked myself in a treatment facility, where they only gave me Gabapentin for Withdrawals & another med I can’t think of right now, dosen’t matter because neither med worked on Subutex Withdrawals.
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The issue is not only getting more clinicians trained to prescribe buprenorphine but getting those who are trained to actually begin treating those with opioid use disorder. Many get trained but never begin treating people. The actual logistics of treatment are somewhat complicated and require changes in workflows, etc in outpatient offices. Not an excuse but a reality.