乌鸦传媒

In this video, Jeremy Faust, MD, editor-in-chief of 乌鸦传媒, sits down with Sarah Wakeman, MD, and Alister Martin, MD, to discuss the evolution of opioid addiction treatment over the last two decades.

Wakeman is the medical director for substance use disorder at Mass General Brigham (MGH) and an associate professor of medicine at Harvard Medical School in Boston.

Martin is faculty at the MGH Center for Social Justice and Health Equity at Harvard Medical School and Founder of , a campaign aimed at transforming emergency departments (EDs) nationwide into the front door for recovery for patients with opioid addiction.

The following is a transcript of their remarks:

Faust: The opioid crisis in this country -- you could say it started a long time ago in the '90s and in the 2000s. When I trained, there was no such thing as over-prescribing opioids. You couldn't get addicted, we were told. Then I think the pendulum swung in other directions as well, in terms of maybe we're undertreating pain now because we're concerned about addiction and use disorders.

So, I know your voice is taxed, but we'll start with Dr. Wakeman. Give me a sense of where you think we are in 2023 versus two other data points in time, 2014 and 2004. Through the decades.

Wakeman: Great question. I think time matters when we think about solutions, because the overdose crisis is not static.

So you're right that it started out with overdose deaths due to prescription opioids, but that changed, really. Opioid prescribing started decreasing and prescription opioid-related deaths started decreasing in 2012. Rather than seeing people's lives saved or people stopping dying, what we saw is actually that people started dying at a faster rate, first from heroin, which was sort of the second wave of the crisis, and then from illicitly manufactured fentanyl, which was the third wave of the crisis.

So I think that gets to the urgency of not thinking about this from the supply side of the equation, which is often where we have gone to with drug policy or other interventions, but thinking about the demand side of the equation. How do we upstream and address the reasons why people are using drugs in the first place? So, address social determinants of health, racism, poverty, inequity, adverse childhood experiences, all of those pieces.

How do we treat people who have opioid use disorder? And not everyone who dies from an opioid overdose has opioid use disorder, but for people who do, we have effective treatment. Then how do we keep people safe? Because no one should die from an opioid-related overdose.

So I think in 2004, we were in the early days of responding to the prescription opioid-related crisis. In 2014, people were just starting to die at faster rates from heroin. And now in 2023, we're actually in what many people would say is the fourth wave of the crisis, which is a polysubstance crisis where people are also dying from stimulant-involved overdoses, from cocaine-involved overdoses. I think we can't even talk about the opioid epidemic anymore, that language is actually dated.

The challenge is that this public health crisis that we're addressing is rapidly evolving, and yet we are often years behind when it comes to our interventions, our treatments, and our strategies. So really keeping pace and thinking about what is a crisis right now and how do we address it.

Faust: Five to 10 years ago, I think a lot of us woke up through programs like , where emergency physicians were told, "Hey, we can actually be a part of the solution here in terms of initiating opioid replacement therapies or medication assisted therapies." The idea being that we'd much rather see patients able to take a safe dose of an opioid or a similar agonist and live their lives normally, go and do things.

Dr. Martin, tell me about the trajectory from your perspective of the Get Waivered story, and then we'll get to the end of it, which is that maybe we don't need to get waivered anymore, right?

Martin: That's right, that's right. The truth of where this started for me is a patient who I fell short in treating, quite frankly. Someone who I let down.

I had a young woman who came to the emergency department very late at night. She was a young mother and she had basically become addicted to opioids and had decided that night that this was not the life that she was going to live, that she wanted to get better. She came to the ED because she effectively couldn't find anywhere else to go. She tried online, she looked up clinics; no one was open, they didn't take her insurance.

So she came to the ER. She said, "Doctor, can you help me?" I was an ER intern in like my first week in the ER in the hospital. And I tell this woman, "Of course we can help you. We're at Mass General Hospital. Don't worry about it."

For the listeners who know this or maybe don't, when you are an intern, you can sort of come up with a plan, but ultimately the attending has to sign off and give you the approval to follow through.

So I go to the attending, I say, "Look, I have this woman, she is here asking for help. I want to get her admitted." I knew about the ACT team, the addiction consult team, because of Sarah's work. So I wanted to get her this consult, I wanted to get her back on her trajectory and get her life back. And the attending, who's a kind, sweet, very intelligent physician, looked me in the eye and said, "Alister, that's just not what we do here. Discharge her."

That walk back from that attending's desk back to that patient's room, where I had to basically give her the exact opposite message that I had left the room with, which was that we're definitely going to help you to now, "No, actually, here's your paperwork. I'm sorry, you have to go now." That for me was the start of the Get Waivered work.

As I began to study the problem and understand it, I learned it wasn't just Mass General that was falling short for patients with opioid addiction. It was effectively every hospital and almost every hospital emergency department across the country. ACEP [American College of Emergency Physicians] did a study looking at, back in 2017, on what is the standard of each emergency department across the country in terms of do they give medication for addiction treatment, or do they kind of just kick people out? In 90%-plus of those ERs, the default was to just give them some paperwork and get them out of there.

So Get Waivered was all about, how do we actually bring up the standard? How do we make it a new standard of care to help people get addiction treatment via buprenorphine or whatever medication would be useful for them? To connect them, plug them in right there at the point of care and turn the ER into the front door for addiction recovery? That's what it was all about.

Principally with all of that, physicians needed to have a DEA [Drug Enforcement Administration] X-waiver to be able to prescribe buprenorphine, and that's what Get Waivered was all about. We ended up getting about 6,000 people DEA X-waivered across Massachusetts and then across the country, we got a big grant to take that show on the road. So we'll get into what the future looks like now that there's been some policy changes, but that's a little bit of the background.

Faust: Yeah. I'll take that baton and just tell the viewers what happened, which is that if you want to go into recovery and get your life back together, medication-assisted therapy -- or there are other ways to say that, but the idea is replacing an opioid that's dangerous with one that's safe -- is the evidence-based standard of care. That's the safe way to not die and to live a normal life.

You think that it would be easy to start that, but you'd be wrong. For years and years, only certain doctors could do that in certain situations. What Alister is talking about is how we really changed that. Buprenorphine or Suboxone is the most commonly referred to one nowadays, but you've probably heard of people who are on methadone, and they have to go to get methadone from a dispensary.

All these barriers were in place up until now to get patients something that really ought to be easy to get, because we're trying to save lives. I can't think of another disease, opioid use disorder being a disease, for which the treatment is so hard to get that's life saving. Like, can you imagine if like we said, "Oh, you have a heart condition. You want to get aspirin? Well, that's not going to be so easy for you, is it? We're going to make your doctors have to go to special training and you're going to have to go to special places and [we'll] only give you one day supply" -- it's just madness.

For years and years, Dr. Martin and Dr. Wakeman advocated so strongly to get rid of this program by which only a few people could prescribe buprenorphine, the select few who went through this training, which was a lot of bottlenecks and a lot of red tape and 'sludge' as we call it -- sludge are things getting in your way of doing the thing you want to do.

But then last year -- this year? I can't even remember anymore. The X-waiver was finally taken away.

Wakeman: In December, the waning days of last year.

Faust: Yeah. The X-waiver was removed from law, meaning that starting this year, any person with a DEA license, anyone who can prescribe a controlled substance, can prescribe these very life saving medications.

But Dr. Wakeman, can you tell us what the catch is? Is there a catch here?

Wakeman: Well, there is a potential catch we're all waiting to hear about, which is that the DEA is going to require additional training of anyone who's renewing their DEA license or getting a DEA license to prescribe controlled substances. They haven't yet announced what that training will be, and I worry about any added burden to a really overburdened workforce right now.

So if there is a training that's going to be required, it should be high quality and educational and actually improve the quality of care for people living with chronic pain and people with addiction. I think ideally we treat this like everything else, we bake it into medical education, to residency, and gradually things change.

At the end of the day, as you already pointed out, Dr. Faust, the most important thing is that people are able to access life-saving treatment immediately without barriers. Buprenorphine is safe, effective medication. Dropping any hurdle we can to get it to people who need it is the end goal.

I think Alister, Dr. Martin, did an amazing job of getting people that X-waiver, and probably the greatest success you can ever have is to put yourself out of business and not need to get people an X-waiver anymore. So I think he was a huge part of that change and really the behavior change that went along with it.

Faust: Do you both sense that there's been like a change in our colleagues in how we look at this? I feel it. When I started med school and residency, I had a certain attitude that changed over time.

I feel like, "Okay, everyone gets it. Everyone gets that opioid use disorder is a disease that has a life saving treatment, and it's just a matter of getting rid of the X-waiver and then it'll be easy." But actually I think that's naive, right Alistair? What do you think both locally and nationally is the feeling about this question right now among our colleagues?

Martin: I think you're totally right, Jeremy. I think there are two different problems that are baked in, right there.

There was the first, which was the regulatory hurdle, right? The fact that you had to go out and get this waiver to be able to prescribe buprenorphine. But then the second one was what I would describe as the cultural change element that was necessary, right? This question of, who deserves care? Whose life is worth caring about and whose life is worth treating when they come in with issues?

I think at the end of the day, we are seeing the beginning of what I hope is this inflection point moment in that cultural change where it's becoming the norm to take care of patients with opioid addiction out of the ER.

I'll tell you one thing that really did a lot of work for us at Mass General Hospital, which really began to kind of change the narrative. Think about this Jeremy, who do we hear about in terms of the follow-up for our patients in the ER? All we hear is, "Hey, you remember that patient?" And it's the patient who died or who bounced back or the patient where something was missed. It's all negative.

What we did at Mass General is very interesting. We started giving ER physicians the end of the story for the patients who they were able to care for. We started telling them, "Did you know that the patient who you put on buprenorphine has been in recovery? Did you know that they're now back in their community college program? Did you know they just got married?" The end of the story.

I think that's reminding people that if they do this one thing, it actually could have a big consequence on the patient's life.

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