Opioid Crisis: Reluctance to Prescribe Lifesaving Treatment Must Stop

The opioid crisis in our country has been going on for most of the last decade. According to the National Institute on Drug Abuse, opioid-involved overdose deaths rose from 21,089 in 2010 to 47,600 in 2017 and remained steady through 2019. The next two years witnessed further increases, with 68,630 reported deaths in 2020 and 80,411 in 2021.

As high as the numbers are, there are many more nonfatal overdoses that have serious negative consequences to the individual’s physical and emotional health, as well as social and occupational well-being.

Thankfully, medications for opioid use disorders (MOUD) are effective. They have been associated with decreases in opioid-involved overdose mortality and morbidity. The FDA approval of buprenorphine and buprenorphine/naloxone for office-based treatment of OUD in 2002 was revolutionary as they could be prescribed and dispensed outside of a federally qualified opioid treatment clinic, a major impediment to widespread prescription of methadone. Not only is buprenorphine as effective as methadone in managing OUD, but also it is safer as it has less abuse potential and less likelihood of causing respiratory depression.

Long-term maintenance on an opioid agonist is now the current standard of care worldwide for the treatment of OUD. Despite this development, however, a JAMA Network Open study published March 23, 2022, reported that only 27.8% of individuals who needed MOUD received treatment in the past year. Indeed, research has consistently shown a major gap between the number of individuals in need of treatment for OUD and the number of physicians available or willing to provide treatment.

There are many reasons for the low use of buprenorphine and access to care, including stigma, health care disparities/discrimination, insurance coverage challenges, and physician concerns regarding diversion of buprenorphine. In addition, the initial stringent regulations regarding buprenorphine prescription imposed by the government after its approval for treatment sent an unintended message that buprenorphine was a dangerous medication that should be prescribed with utmost care to avoid liability. That said, the subsequent reluctance of some psychiatrists to undertake the training needed to obtain a waiver to treat patients with OUD, as well as the reluctance of waived psychiatrists to treat these patients, have been quite worrisome. Some waived psychiatrists informed me that the regulations caused them to question their ability to prescribe buprenorphine, so they avoided it altogether.

As noted earlier, there are many valid explanations for their reluctance to prescribe buprenorphine, but the lack of interest in obtaining the waiver or in treating these patients despite having obtained the waiver is difficult to accept, especially when we are in the throes of a devastating public health crisis driven by opioid-related overdoses. The recent decision by the Substance Abuse and Mental Health Services Administration and the Drug Enforcement Administration to no longer require the X waiver, including the current mandated training, is a welcome development intended to encourage more physicians to prescribe it.

Electing to not utilize the tools available to save lives and for which we are uniquely qualified risks violating our medical ethics in multiple ways, including the oldest ethics injunction to always act in the best interest of patients (beneficence) and to avoid harm to patients (nonmaleficence). In the absence of systemic or other well-founded barriers, psychiatrists’ refusal or reluctance to treat indirectly causes harm to patients as evidenced not just by overdose deaths but also other negative consequences to patients such as poor physical and emotional health and social, occupational, and financial adversity. In so doing, psychiatrists are abrogating the duty entrusted in them by vulnerable patients and society to protect them. In addition, psychiatrists risk coming across to patients as lacking compassion, empathy, or care—character traits of virtuous physicians.

Guidance from The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry makes clear that a psychiatrist shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights (Section 1); maintain a commitment to medical education; make relevant information available to patients, colleagues, and the public; obtain consultation; and use the talents of other health professionals when indicated (Section 5). As such, psychiatrists lacking confidence to prescribe buprenorphine are required to seek and obtain necessary help to enhance their confidence as patients’ lives depend on them. Further, psychiatrists are required to recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health (Section 7), regard responsibility for the patient as paramount (Section 8), and support access to medical care for all people (Section 9).

In summary, the opioid crisis is a public health crisis associated with high mortality. Treatment to contain the crisis is readily available, but the treatment is not without risks. However, psychiatrists are not unfamiliar with and, in fact, currently embrace treatments with dangerous and even life-threatening side effects, including psychotropic medications. The potential to alleviate suffering eclipses the risks of debilitating side effects and potential liability and gives psychiatrists the courage to proceed. The same courage and will are needed to confront the opioid crisis head on, countermand psychiatrists’ discomfort, and concentrate on the core ethical injunction to save lives. ■

Charles C. Dike, M.D., M.P.H., is chair of the APA Ethics Committee and former chair of the Ethics Committee of the American Academy of Psychiatry and the Law. He is also an associate professor of psychiatry; co-director of the Law and Psychiatry Division at the Yale University School of Medicine; and medical director in the Office of the Commissioner, Connecticut Department of Mental Health and Addiction Services.