No matter the approach, it seems to be getting increasingly difficult to address the massive opioid epidemic facing the United States.
We are facing two epidemics that rival each other in scope, not only the widespread overprescribing of traditional opiates for chronic pain, which has led to our national opiate crisis, but also the epidemic of untreated severe daily pain across the country.
Chronic pain affects more than 100 million Americans, more than diabetes, heart disease and cancer combined. We sometimes turn to opiate pain medications simply because other non-opiate pain medications are contra-indicated in these patients, or have serious side effects of their own (anti-inflammatories for instance).
What we need are new classes of medications that can still treat these millions of Americans suffering every day, that have proven effectiveness and less chance of abuse than traditional opiates. Fortunately, there is another way to address this crisis without leaving those with severe chronic pain unable to access treatment.
The Drug Enforcement Administration classifies medications into five Schedules ranking them based on their risk for addiction, with Schedule I carrying the highest risk and V the least. Most commonly prescribed opioids — morphine, oxycodone, hydrocodone and fentanyl — fall into Schedule II. Buprenorphine, however, is a different kind of opioid and falls into Schedule III, meaning it carries less risk for abuse and addiction.
Buprenorphine, which can be used for pain relief without the same risk for abuse as other, commonly prescribed opioids, is also widely used in treating opioid addiction. It has a great track record in safe and effective treatment, not only in those suffering with addiction but also in those with chronic pain. In addition to its Schedule III designation, what also makes buprenorphine different is the way it affects the respiratory system.
Most opioids, when taken in increasingly large doses, will carry an increasingly greater risk of respiratory depression, which can be fatal and is often the cause of death in an overdose. Buprenorphine, on the other hand, has what has been described in the medical literature as a respiratory “ceiling effect” that limits respiratory depression at higher doses.
There are, however, numerous administrative roadblocks to widespread buprenorphine use. Many insurance companies currently offer either woefully inadequate coverage of buprenorphine, or they require physicians to first prescribe riskier generic Schedule II products before they will begin a lengthy approval process for buprenorphine coverage.
This is simply unacceptable. The Schedule II drugs, on the other hand, face few or no administrative barriers since they save insurance companies money in the short term. This practice is both dangerous and short-sighted, as while insurance companies may limit costs in the immediate future by first trying Schedule II drugs, they could face fewer long-term costs if they simply allowed patients improved access to the most safe and effective treatments from the start.
These roadblocks, however, are also bureaucratic in nature. For example, the Centers for Disease Control prescribing guidelines do not distinguish between buprenorphine and Schedule II products, and actually suggest doctors begin with more addictive Schedule II opioids before moving on to buprenorphine. Many insurance providers have used these guidelines as their rationale for providing low-priced generic Schedule II drugs as their preferred options.
If insurance companies and the relevant government agencies finally work to amend misguided regulations, we may finally be able to take the first crucial steps to limit the opioid epidemic plaguing our nation. It is imperative we ensure that those living with chronic pain have access to medication that can alleviate their condition with less risk for addiction and overdose than they currently face.
We can overcome the opioid epidemic, and treat the chronic pain epidemic as well, but first we must recognize the tools at our disposal and make sure they are accessible as a first option. By increasing access to buprenorphine, we can tackle these crises on both ends of the spectrum, by providing medical professionals with the tools to deliver safer and more effective treatments.
