Alabama doctors say new proposed rules aimed at clinics that provide medication for addiction could make it harder for patients to get care, even as overdose rates rise to record levels.
The effort comes more than two years after Alabama legislators passed a bill to impose more regulations on clinics that prescribe buprenorphine. Two studies found that 40 percent of patients who received the medication stayed in treatment for at least a year, according to Nature. However, legislators worried about clinics spreading like “pill mills” and requested new rules from the Alabama Board of Medical Examiners.
Dr. Ellen Eaton is an infectious disease specialist at UAB who treats patients with HIV and opioid use disorder. Last month, she took to Twitter to urge patients and providers to speak out against requirements that could require visits every two weeks for some people who use medication to control opioid cravings.
“Coming in every two weeks is difficult for any patient,” Eaton said. “I couldn’t make it to my doctor every two weeks. But imagine being unhoused. Imagine being recently out of a rehab facility. Trying to get your kids back or a job. I have many patients who can’t get time off work because they are new to a job.”
Alabama’s move to tighten regulations on addiction treatment comes as federal agencies move in the opposite direction. After years of discussion, the Substance Abuse and Mental Health Services Administration dropped rules requiring training and limitations on the number of patients doctors could treat with addiction medication. Agency officials decided doctors with licenses to prescribe controlled substances such as opioids should also be allowed to prescribe medication to treat addiction to those substances, Eaton said.
Buprenorphine, which is sometimes sold as the medication Suboxone, is one of the most common FDA-approved treatments for addiction. It helps patients control cravings for drugs and can help prevent fatal overdoses by partially blocking the brain receptors for opioids, Eaton said.
“From my perspective as a provider-prescriber, I have seen this drug really change lives,” Eaton said. “And the research supports that. That is can really be a game-changer in keeping people alive and getting their lives back on track.”
This fight is happening as the state and nation grapple with alarming increases in overdose hospitalizations and deaths. The number of overdose-related ER visits in Alabama increased from 12,343 in 2016 to 15,361 in 2021, according to the U.S. Centers for Disease Control and Prevention.
Alabama is also set to receive hundreds of millions of dollars in opioid settlement funds from lawsuits against companies that manufactured and marketed prescription pain pills. A committee tasked with prioritizing spending said a large portion of it should be used to increase access to medications like buprenorphine. In a recent presentation, members of that committee said 20 counties in the state have no opioid treatment program.
Many patients must travel long distances to seek care, Eaton said. Requiring patients to visit the doctor every two weeks or ween off medications for anxiety as a condition for receiving buprenorphine could discourage people from seeking care, she said. That could increase the number of overdoses.
In a statement, members of the Alabama Board of Medical Examiners said legislators required new rules to prevent the abuse of buprenorphine. The treatment contains an opioid and naloxone, which counters the effects of the opioid. Users can feel high, but the sensation is muted compared to heroin or fentanyl, according to Harvard Medical School.
In 2020, members of a committee first proposed rules to regulate addiction clinics. Those rules attracted a lot of criticism, and the board of medical examiners shelved them during the pandemic.
Alabama Board of Medical Examiners Executive Director William Perkins said the committee is still considering changes to the buprenorphine rules.
“We are listening to and working with physicians and health care advocates, including UAB, to hear their suggestions on ways to improve the proposed rules before they are implemented,” Perkins said.
The senior vice president of medicine at UAB, Dr. Anupam Agarwal, said the university is working with the board to address physicians’ concerns.
“A UAB workgroup was created and has been working actively with the Alabama Board of Medical Examiners to share feedback about the proposed Buprenorphine rule and is collaborating with BME to address concerns raised by physicians with hopes of achieving a positive outcome regarding the rule for health care providers and patients,” Agarwal said.
Alabama has long had the highest number of opioid prescriptions per capita, but those numbers have fallen in the state and across the nation in recent years. Although prescription opioids once drove the overdose crisis, they have now been overtaken by heroin and fentanyl sold on the street. Eaton said state officials recently announced that fentanyl had been found in illicit drugs passed off as Adderall, methamphetamine, cocaine and marijuana gummies.
In 2013, prescription opioids accounted for four of the top five causes of overdose death. By 2017, fentanyl and heroin had rocketed to the top and prescription pain pills no longer appeared in the top five, according to the Alabama Department of Public Health.
“There is a bit of a disconnect in what I’m hearing at the state level is driving the crisis and the response, which is tightening restrictions on physicians,” Eaton said.
In addition to creating barriers for patients, Eaton said the proposed rules could prevent some doctors from prescribing buprenorphine. The changes to federal law were supposed to make it easier for family doctors, obstetrician/gynecologists and others to treat addiction.
“My main concern is that patients will not have access to care, the most vulnerable,” Eaton said. “And that providers who are primary care providers who are well-positioned to respond to this are already burned out after the last few years and then we give them multiple pages of new requirements. The last thing we need are fewer doctors prescribing buprenorphine.”