Lisa’s Legacy: How the Buprenorphine X-Waiver Costs Lives

August 20, 2019

The young woman paced frantically around the hospital room, dark bags under her bloodshot eyes. Sweat beaded across her pale forehead, and frothy spit accumulated at the corners of her mouth. She looked much older than what it said on her chart. 

She was my first patient of the night. As I helped her into the stretcher, I noticed her brisk, shallow breathing and the track marks all over her clammy arms. She looked at me with exhaustion and despair. 

I introduced myself as the doctor and sat beside her.

“Please, help me,” she murmured in a frail voice. “I don’t want to go back to using, but I can’t take it anymore.” 

I immediately glanced at the nurse, who shook her head and said detox was full. The young woman sighed and looked away, tears rolling down her face. Then she told me her story. 

Lisa, as I will call her, had been injecting heroin for the past six months. She lost her job, and her two daughters had moved in with her grandmother. She wasn’t a drinker and never used drugs growing up. A 24-year-old college graduate, Lisa was on the path to becoming a real estate agent when her life took a sudden turn in 2016. 

She was hit by a drunk driver and left with serious injuries. “It was bad,” she sighed. For weeks, she was in the intensive care unit for a traumatic brain injury. She suffered multiple fractures, including three in her lower lumbar spine, ultimately requiring spinal fusion to stabilize her back. The years after her accident were defined by pain. 

Then Lisa’s doctor—without any warning⁠—stopped all her pain medication.

Before long, Lisa’s doctor had her on a fentanyl patch and 150 mg of oxycodone per day. Her life revolved around her pain medication, as severe withdrawals set in if she went without it for more than six hours. 

Then, with increased pressure by the medical community to reduce the number of opioid prescriptions, Lisa’s doctor⁠—without any warning⁠—stopped all her pain medication. 

“He said it would be for my benefit, and that I would need to go to the pain management clinic if I wanted help,” Lisa told me. “I felt completely betrayed. I must have gone to 10 doctors, and no one wanted to help me with my pain and addiction. I didn’t even have a chance to wean off the medication. I didn’t know what to do.” 

Like so many other patients in this position, Lisa began using heroin because it was the only opioid she could access. 

When Lisa came to me as a patient, she wanted change. Her opioid addiction had ruined her life, a problem she shared with countless others.

The perfect storm we are currently reckoning with was initially fueled by profit-hungry pharmaceutical companies that used false data to aggressively market opioids to prescribers, combined with deprivation and inequality in many areas of society.

But as overdoses skyrocketed, there was growing pressure on physicians from government monitoring programs, physician-run organizations and the media, to curtail prescribing. In the years following 2012, prescription opioids became unavailable to many patients without warning; according to the CDC, total prescriptions were down 30 percent in 2017 compared to 2012. Concurrently, drug cartels flooded the streets with cheap, plentiful heroin and illicit fentanyl. Opioid-involved overdoses killed 47,600 people in 2017.

Buprenorphine was approved by the Food and Drug Administration for the treatment of opioid use disorder back in 2002. Most commonly given as a sublingual film under the brand name Suboxone, buprenorphine is itself an opioid and by no means a cure for addiction. However, its unique mechanism of action does not provide the same euphoria, or “high,” as traditional opioids, and it is very unlikely to cause an overdose. Simultaneously, it decreases cravings and prevents withdrawals. People who are prescribed buprenorphine are much less likely to seek opioids on the illicit market, and mortality is greatly reduced.

Lisa begged me for a Suboxone prescription. Unfortunately, I did not have the authority to do this, and neither did any other doctor in our emergency department.

Despite improved medications, increased funding, extensive media coverage and the declaration of a national emergency, buprenorphine⁠—and addiction treatment in general⁠—remain unavailable to many who need help.

That night, Lisa begged me for a Suboxone prescription. It was a reasonable request, considering it was her only chance to resist buying heroin upon leaving the hospital. Unfortunately, I did not have the authority to do this, and neither did any other doctor who worked in our emergency department at that time. I was not even permitted to give her a dose in the ED, due to a hospital policy that limited its use to patients with an active prescription. 

To prescribe Suboxone, a physician must obtain a special license from the Drug Enforcement Administration known as the X-Waiver, which requires additional training and places doctors under further regulatory scrutiny. What’s more, after all that bureaucratic rigmarole, a licensed physician can only prescribe Suboxone to a maximum of 30 patients a year. 

It is estimated that less than 1 percent of emergency physicians carry an X-Waiver, and those who do can fill their annual quota in a matter of days. The X-Waiver requirement was created by the Drug Addiction Treatment Actco-authored by Senators Orin Hatch, Carl Levin and Joe Bidenwhen the overdose crisis was still in its infancy in 2000. Since then, it has drastically restricted the number of physicians who can effectively treat opioid addiction. 

After explaining to Lisa why I could not prescribe Suboxone, I had no choice but to discharge her with nothing more than a prescription of the opioid overdose reversal medication Narcan (naloxone). I was letting my patient down, and I knew she would immediately resort back to heroin. 

When Lisa exited the emergency department, she turned and looked at me. She wore a bright jumpsuit, and as she walked away with her head down and feet dragging, she looked like a prisoner on the way to an execution. 

Overcome by guilt and frustration, I banged my fists on my desk, yelling, “This is bullshit. She is going to fucking die, and we did nothing!” 

The charge nurse glanced over at me and replied flatly, “No one forced the needle in her arm.” 

I was working again the next evening after Lisa was discharged. The ED was packed, as usual, and I was paged overhead to pick up a phone call from the EMS dispatcher. 

“Hey doc, just wanted to give you a heads-up. We were called to the scene of a 32-year-old female found cold and stiff. Poor bastard still has the needle in her arm. We’re bringing her straight to the morgue.” 

I reluctantly asked her name, and sure enough, it was Lisa. I slammed the phone down, tears building. The chaos of the ED hushed into a cool silence. The young girl who had begged me for help not 24 hours prior was dead. 

For months, I was haunted by the look on Lisa’s face. 

This story is not unique. Every emergency physician sees a patient like Lisa nearly every day, and chances are, they can’t provide the treatment that could save their lives. 


Special thanks to Hayden F.W. Hard and Mira Bishawi for helping with the writing of this article.

Photo by KOMU PHOTOS/ Eric Staszczak via Flickr/Creative Commons

Hugo Hanson

Hugo Hanson, DO is an emergency medicine physician living and practicing in New York’s Hudson Valley. He has specific interests in toxicology and addiction medicine. He is currently consulting for hospitals on how to improve treatment of addiction from the emergency room, and working with local and state organizations to expand addiction services.

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