Going Beyond the Waiver

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For all the talk about “getting people into treatment” during this overdose crisis, treatment is incredibly difficult to get. Medicated-assisted therapy is the primary way of treating opioid use disorder when medications like methadone or buprenorphine are prescribed to reduce withdrawal symptoms. These drugs are opioids as well—and form the basis of medicated-assisted therapy by reducing pain symptoms and acting over a long period of time. However, they aren't as strong as drugs like heroin and don't produce the same high. This allows people in recovery to transition off of opioids without experiencing severe withdrawal symptoms. While officials across the U.S. have made platitudes towards expanding treatment, the reality is that the state often stands in the way of recovery.

Take methadone for instance: It has to be prescribed in specialized clinics. This is a vestige of policy from the 1970s, when methadone was initially approved for use in treatment. Since the drug is an opioid and can therefore be habit-forming, policymakers were concerned that by allowing access to methadone, they would be allowing people access to another drug to get addicted to. Therefore, tough regulatory measures were passed, beginning with the 1974 Narcotic Addict Treatment Act, all of which ensured methadone could only be dispensed through clinics.

These settings can be stigmatizing to people who use drugs, and people sometimes have to travel long distances to get treatment. Buprenorphine, another drug used for treatment, can be prescribed by doctors—but only by those who have a waiver from the Drug Enforcement Administration. This practice of obtaining waivers was first outlined in the 1974 act for methadone when doctors were required to register with the DEA, but when Congress acted to make sure buprenorphine was available to patients—passing the Drug Addiction Treatment Act in 2000, the old practice of obtaining a waiver was retained.

This waiver requires additional training and allows the DEA access to patient records. Currently, less than 7 percent of U.S. doctors have a buprenorphine waiver. Doctors have repeatedly called upon the government to get rid of this archaic system of licensing.

These barriers to treatment end up reinforcing existing racial disparities. Earlier this month, a study published in JAMA showed that White patients had higher odds of receiving buprenorphine at an office-based visit than Black patients. This complements a similar study done in New York City, which showed that buprenorphine access was higher in regions that had higher incomes and lower percentages of Black and Latinx people. This raises an important question: Are Black patients less likely to receive buprenorphine during a visit or are they less likely to have access to a doctor with a waiver? In other words, is this merely an issue of access or are Black patients being denied medication due to racist prescribing practices?

We know that racial disparities in health outcomes often are the result of the segregated nature of neighborhoods in America. But we also know that Black patients are less likely to be prescribed pain medication and can be stereotyped as “drug seeking.” Merely having access to a doctor does not mean that that doctor will prescribe what the patient needs.

With only 7 percent of doctors licensed to prescribe buprenorphine, it’s more likely that Black patients do not have access to a licensed doctor in their area. Still, this serves as an important reminder that merely lifting the waiver is not enough. We must ensure that all people, regardless of race or income, have immediate and unquestioned access to treatment. This means our conversations about treatment access need to be connected to the broader discussion about how communities of color access healthcare. If people of color, specifically Black people, are denied medication at large, then access to addiction treatment won’t be much better. To ensure equitable treatment for opioid use disorder, existing disparities in the health care system must be addressed.