Why is Buprenorphine Not Widely Available?

Regulatory Barriers

Buprenorphine was approved by the food and drug administration for the treatment of opioid use disorder (OUD) in 2002, making it the first medication to treat OUD that can be prescribed or dispensed in physicians offices - unlike methadone which must be dispensed in a specially certified opioid treatment program (OTP).

However, in order to prescribe or dispense buprenorphine for the treatment of OUD prescribers must undertake a specific training and receive a waiver required by the Drug Addiction Treatment Act of 2000 (DATA 2000) that allows them to use Schedule III, IV, and V medications to treat opioid dependency.

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Stigma

There has also been historical stigma around medications to treat opioid use disorder that in based on misinformation. Medications for opioid use disorder are actually opioids that are used to treat opioid use disorder. This is a bit confusing and has contributed to a misconception that using medications to treat opioid use disorder is “swapping one drug for another.” This is incorrect. As you may remember from earlier articles, there is an important distinction between dependence and addiction. Dependence is a physical dependence on a substance - which means without it the person may experience withdrawal. Addiction refers to the behavior change and harmful consequences associated with the substance use. So someone can be dependent on a substance but not addicted to it. As an example, a person with diabetes is dependent on insulin, but we would never say they are addicted to it.

Medications for opioid use disorder can be thought of in the same way. However, at first, many addiction recovery groups denounced the use of medications to treat OUD, wrongfully calling them a crutch or telling people on medications that they are not really in recovery. This has been extremely harmful and resulted in slower adoption of these lifesaving medications. Now, many of these groups have changed their stance and openly accept and even encourage the use of medications to treat opioid use disorder but progress has still been slow.

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Financial Incentives

The financial incentives within the addiction treatment industry have been misaligned. Treatment with buprenorphine can be conducted in an outpatient setting such as a doctor’s office. If a person receives oral buprenorphine from their doctor on a weekly basis, along with substance use counseling, individual and group therapy, and toxicology testing, the reimbursement rate for the services is roughly $1,000 per month. Historically though, addiction treatment has been delivered in residential settings which can cost on average $6,000-$20,000 for 30 days.

Therefore, the system of addiction treatment facilities is set up to deliver more expensive, acute care and has not been financially incentivized to deliver medications for OUD. Instead, they can continue to deliver the same treatments they always have and make significantly more money. What’s worse is that there is a higher rate of overdose associated with leaving residential treatment. If someone relapses, they often start over and pay again. This means that the system is also not incentivized to keep people well over the long-term.

There are prominent national organizations working on these issues. To advocate further for improved access to evidence-based addiction treatment, check out Shatterproof and Drug Policy Alliance.

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