The number of U.S. fatal drug overdoses has more than doubled in the past eight years, with about 110,000 such deaths in 2022, according to the National Institutes of Health.
The leading cause of death, by far, is fentanyl, which has gone from prescription pain reliever to a synthetic opioid furtively smuggled into the country, and consumed illicitly in pill or powder form.
Behavioral health care providers have, at least, curbed the rise of deaths and hospitalizations, after going through multiple struggles in treating fentanyl, a substance exponentially more powerful than heroin and similar opioids.
“We are going through about the fourth wave of the opioid epidemic,” Adam Bisaga, the medical director at Ophelia, a New York-headquartered company that provides telehealth treatment for opioid use disorder, or OUD, told Addiction Treatment Business. “The way we are treating people has had to change.”
Broadly, there are three ways OUD treatment has changed in recent years.
A growing acceptance of OUD medication among providers
As recently as five years ago, there was a debate about whether patients dependent on fentanyl should take a different synthetic opioid, buprenorphine, that would wean them off addiction.
But today “there is a lot less controversy over whether buprenorphine should be used,” according to Adam Scioli, medical director at Wernersville, Pennsylvania-based Caron Treatment Centers. “The discussion now is based on duration and when to discontinue.”
Fentanyl is such an addictive drug that providers find it necessary to first give patients just two milligrams a day of buprenorphine, even having patients continue to use fentanyl for the first week, Bisaga told ATB.
Afterwards, patients should take 16-24 milligrams per day of buprenorphine, both Bisaga and Scioli said, a possible jump from the FDA’s recommended 16 milligrams each day for OUD treatment.
Added buprenorphine is also the view of a National Institute of Drug Abuse study published in September that said current buprenorphine dosage levels are based on treating heroin.
Regardless of the exact medication level, a consensus has emerged that buprenorphine is a needed first step, before patients are treated for underlying psychiatric issues.
“The patient can then move past addiction, and begin with the real problems they need to solve like relationships and finances,” Bisaga said.
A more active relationship with pharmacies
But if providers see buprenorphine as necessary, pharmacies are skittish.
In July, Scott Weiner, director of research at Bicycle Health, published a research letter in the Journal of the American Medical Association, regarding what U.S. pharmacies had in stock buprenorphine and naloxone, the emergency opioid antidote often under the brand name Narcan.
Weiner found that just 57% pharmacies carried the OUD drugs in stock, a finding that bolstered prior studies that pharmacies, including Walmart, worry about regulatory penalties or liability from fraudulent prescriptions or drug misuse.
“Pharmacies are scared of being sued,” Bisaga said. “We are spending a lot of money because we are calling various pharmacies.”
“One of the biggest challenges is still pharmacies,” Weiner also told ATB.
Part of pharmacist’s fear, Weiner argued, is a possible misunderstanding that the opioid crisis is being caused by misuse of prescription opioids. In fact, he said, the vast majority of OUD patients are taking fentanyl imported into the country and sold in the illegal drug market, often mixed to increase the potency of another drug.
Whatever the reason, providers are having to “weed specific pharmacies out,” Scioli said, and direct patients to carefully selected partners who have agreed to prescribe OUD medication.
Providers are trying to instill an “attitudinal shift,” Scioli said, with pharmacists.
More frequent, if remote, check-ins
Creating more touchpoints with patients has also been an important development.
“With fentanyl, the relapse rate is much higher, and there is an urgency,” Scioli said. “You need to continue to monitor the patient very closely with not just the signs they exhibit, but the symptoms they report.”
Part of the reason, Weiner said, is a lack of clarity regarding what patients are using. When patients misuse prescription drugs, it is easier to determine medication or dosage than an opioid purchased illegally, where the amount of fentanyl, and what it may be mixed with, is unclear.
At Ophelia, Bisaga said, telehealth counselors check-in a few times a week and even every day when patients begin taking buprenorphine.
Recently, the Drug Enforcement Administration extended a COVID-era change letting buprenorphine be prescribed over telehealth. Still, even if prescriptions can be made remotely, telehealth’s financial future depends on insurers.
“We have to negotiate bundle payments with insurers,” Bisaga said. “Right now, we cannot bill for three-times-a-week visits.”
Whether more frequent check-ins can be reimbursed is a looming challenge. For now, Bisaga said, patients benefit from continual “education and assurance.”