The Advisory covers all three Food and Drug Administration-approved MOUD, but the crux of it is about buprenorphine (commonly known by brand name Suboxone). Unlike methadone, which is confined to its own clinic system, and naltrexone, which is unhelpful, bupe is an evidence-based medication that can be picked up from a pharmacy once a month like most other prescriptions. It’s the most widely prescribed of the three MOUD, but access is still limited in many regions and for many demographics, and patients and prescribers alike still face inordinate surveillance from the Drug Enforcement Administration. In recent years, there’s been a growing push for pharmacists to be able to prescribe bupe to patients directly.

Some pharmacists have been able to prescribe bupe through collaborative practice agreements with licensed physicians—but only in the minority of states that authorize them. In 2022, the Mainstreaming Addiction Treatment Act eliminated the X-waiver and allowed bupe to be prescribed to more patients by more types of providers, including pharmacists, with fewer bureaucratic hurdles. But pharmacists’ ability to prescribe bupe was still restricted at the state level.

In late 2025, the SUPPORT Act authorized DEA-licensed pharmacists to prescribe bupe independently after completing an eight-hour training that’s specific to buprenorphine (rather than one more broadly focused on substance use disorder). But to date, only California and Idaho have approved pathways for pharmacists to prescribe bupe independently.

“A pharmacist’s ability to prescribe and dispense MOUD is especially important for communities that have limited access to or awareness of OUD treatment,” the Advisory states. “[P]harmacists are often the first point of contact on the continuum of care for people with OUD, and most pharmacies have longer hours of operation than other medical providers. These considerations mean that, where state laws allow, DEA-registered pharmacists are well-positioned to provide patients with streamlined, low-barrier access to MOUD.”

“Medication diversion is a complex topic and is often misunderstood,” the Advisory states.

SAMHSA has recently been shifting its rhetoric around long-term MOUD maintenance toward tapering, validating the very dangerous idea that bupe and methadone are only step-downs on the road to “full” abstinence—which encourages scrutiny of the many people who have been stable on those MOUD for years or even decades. But rather than push the concept, the Advisory frames tapering only as a possibility that some patients might decide to pursue, while “clinical experience shows that [others] may require long-term treatment with medications.”

It also addresses pharmacists who might be wary of prescribing bupe to patients who also use other substances besides opioids, stating that in the context of the overdose crisis “it is safer to initiate MOUD without requiring abstinence from multiple substances.”

Urine drug-testing is discussed only briefly, to note that the practice “may be useful for assisting with treatment adherence,” but in isolation “has limited utility and effect on patient outcomes,” and “may be viewed as punitive by patients.”

For pharmacists concerned about “diversion,” meaning the bupe getting used in some way it wasn’t meant to, or by someone it wasn’t prescribed to, SAMHSA states that they shouldn’t decline to fill a prescription without first talking to both the patient and provider.

“Medication diversion is a complex topic and is often misunderstood,” the Advisory states. “Pharmacists who have concerns about the prescribed buprenorphine treatment regimen should not automatically decline to dispense it … buprenorphine is rarely associated with fatal overdose, and, when it is, other substances are almost always present.”

The government is always lamenting how there are too many barriers to accessing bupe even though its risks are negligible, how the overdose crisis makes this a matter of utmost urgency, how only a fraction of the people eligible for a prescription are able to get one. Then when the people take matters into their own hands it’s called “diversion,” and we have to stop them before too much life-saving medication gets into the community, where just anyone could take it. This is why these resource guides always overlook the fact that the more appropriate way to dispense bupe, compared to the current restrictive setup, would be to just launch it into the streets with a T-shirt cannon.

Image (cropped) via California State Board of Pharmacy

The post SAMHSA Pubs Surprisingly Harm Reduction-y Guide for Pharmacists Prescribing Bupe appeared first on Filter.

This is the fourth temporary extension and will expire in one year—a time frame comparable to the previous extensions, and one the DEA feels is short enough that it will not, amid an ongoing opioid-involved overdose crisis, risk the public gaining too much access to lifesaving medication.

Since 2008, an amendment to the Controlled Substances Act had barred patients from receiving prescriptions for controlled substances via telemedicine alone, requiring that they first attend at least one appointment with a provider in person. This was a particularly high barrier for bupe, which is under Schedule III, for a number of reasons, including the medical field’s overwhelming hostility toward people with opioid use disorder.

In March 2020, when the COVID-19 pandemic made in-person appointments a public health risk, the DEA granted temporary exceptions to the requirement that specifically cleared providers to prescribe bupe to patients they spoke with on the phone, even without a video component. This temporary rule was extended to late 2023, then extended a second time to late 2024, and then a third time to December 31, 2025.

This extension will last until the end of 2026, in an effort to forestall what the DEA refers to as the “telemedicine cliff.”

Now, the fourth temporary extension will take effect January 1, 2026 and last until the end of the year, to forestall what the DEA refers to as the “telemedicine cliff”: patients who’d been receiving medication from providers they hadn’t met in person being abruptly cut off when the temporary exception finally expired and no permanent rule had replaced it. This would not only disrupt lifesaving treatment for many patients, but would overwhelm providers with a backlog of requests for in-person evaluations.

“DEA has received numerous communications from patients, providers and other stakeholders warning that expiration of the current telemedicine flexibilities, without further regulation, could potentially and abruptly limit patients’ access to care until promulgation of a final set of regulations,” the agency wrote in its new temporary rule. “The potential harms are widespread. To put it into context, one stakeholder summarized unpublished data reviewed by Epic, Johns Hopkins, and Stanford: of an estimated 44.6 million prescriptions for controlled substances prescribed across 258 organizations in 2024, more than 7 million, approximately 16 percent, were issued without a prior in-person medical evaluation.”

In January, the DEA issued a separate final rule that further expanded telehealth bupe access, clearing providers to prescribe bupe to new telehealth patients for up to six months even if they hadn’t met for an initial in-person appointment. But before the rule actually went into effect, President Donald Trump was inaugurated and all federal rulemaking was suspended. The deadline for implementation was pushed back to February, then March, then finally to December 31. As the now-permanent rule for buprenorphine obviously has a lot of overlap with the newly extended temporary rule for all controlled substances, prescriptions will be considered compliant as long as they fall in line with either of them.

A recent JAMA Psychiatry study estimated that from 2019 to 2020, the portion of United States outpatients who accessed mental health services via telemedicine went from 0.4 percent to 46.1 percent. Between 2021 and 2022, one out of every four US outpatients accessed mental health services via telemedicine. The same study found that compared to other patients, those prescribed bupe were less likely to receive any kind of telemedicine mental health care services.

Image via National Cancer Institute

The post Feds Extend COVID-Era Bupe Telemedicine Flexibilities, Again appeared first on Filter.

In the corner just behind a tall, iron gate, a group of patients gathered. In the center, an old woman lay on the pebbled ground, talking loudly in a scratchy voice between drags from her cigarette. A man wearing stained jeans and holding an extra-large Circle K cup stood beside a younger woman in flannel pajamas, and chunky black slides. The officer had also noticed this congregation and was walking toward them; according to a posted sign, no loitering was allowed on the premises. I guided my bicycle to the rack behind them, a little worried whether it would still be there when I returned. 

It was January 2020, and I was applying to work part-time as a physician at a methadone clinic. Primarily an emergency room doctor, I had become increasingly interested in addiction medicine over the past few years. 

To gain credibility—something I was always chasing as a young woman in medicine—I decided to pursue board certification in the field. This meant that I needed to work at least 500 clinical hours in addiction, and in Tucson, the only place looking for help was a methadone clinic. I had never imagined myself working somewhere like this; methadone clinics weren’t exactly seen as desirable. Nobody in my medical school aspired to work at one, nor was it presented as a career goal that we might strive for. But here I was, in a nice dress and leather boots, with freshly washed hair, ready for my interview. 

If my doctor asked me to follow such condescending, punitive rules, I would be outraged. But if you wanted methadone, there was no choice but to comply.

Swinging open the tinted glass door, I entered the buzz of the crowded waiting room. A line of patience formed to my right, waiting to get their daily doses. The air smelled of stale cigarettes and cherry cough syrup, the flavor added to the liquid methadone. Many of the patients had sunburned shoulders, and a few had cheap, thin roller bags that they dragged alongside them—signs of housing insecurity. 

To my left was a sea of vinyl chairs filled with patients, waiting to see therapists, clinicians, or lab techs. Several times a year, patients were randomly selected to give a urine sample to determine whether they were still using drugs. They peed into cups held over toilets with silver handles taped in place to remind them of the rules, which were printed on a piece of paper, highlighted in yellow, and tacked to the rear wall—no flushing the toilet or running the faucet, even though there was no sink inside the small bathroom itself. There was no lock on the door. The freshness of the sample was verified by a flimsy thermometer attached to the cup. 

The printed rules also detailed what happened if someone couldn’t pee within three minutes: If they decided to leave the clinic instead of waiting in the lobby and trying again, a staff member would watch them urinate when they next returned.  

If my doctor asked me to follow such condescending, punitive rules, I would be outraged. I would demand to see their policies, argue with the staff, or storm out. But if you wanted methadone, there was no choice but to comply. 

…

[The previous year, the author had received a shocking letter about her Suboxone (buprenorphine) prescribing.]

Much like text messages from my mom, the letterhead was in all caps, and the sender was none other than Michigan’s Medical Board. It was definitely not an award. 

“Dear Licensee,” it began. “Enclosed is an Administrative Complaint, charging you with violation of the Public Health Code. You must respond to this Complaint IN WRITING WITHIN 30 DAYS from the day you received it. If you fail to do so, the complaint will be sent to your Board’s Disciplinary Subcommittee to impose a sanction…” 

I flipped to the next page, and there, to the bottom of the page, I found my first clue: “Suboxone is known as ‘prison heroin,’ and is commonly abused and diverted.”

Prison heroin? Really? Suboxone was increasingly seen as a gold-standard treatment for opioid use disorder; it was not some fringe illicit drug. The letter read less like one from an official medical board, which was supposed to be based in science, and more like propaganda from some abstinence- based troll on social media. Yet here it was. 

“From May 2018 through September 2018, Respondent wrote seventeen (17) prescriptions for controlled substances in Michigan … Respondent’s conduct constitutes a violation of general duty, consisting of negligence, or failure to exercise due care, and fails to conform to minimal standards of acceptable, prevailing practice for the health profession…”

The legal jargon was confusing. What had I done wrong? What was at stake? Would I lose my medical license? The last four years of medical school, three years of residency, and one year of fellowship all made obsolete? How would I repay my $262,000 of student debt? 

The board was continuing the century-long tradition of criminalizing maintenance medications and the doctors who prescribed them. Via telemedicine, I was making buprenorphine too accessible. 

In 1981, [drug historian] David Courtwright asked [methadone pioneer Dr. Marie Nyswander], “Which groups would you identify as the most influential opponent of methadone maintenance?” 

She answered, “My feeling was always that the [Federal Bureau of Narcotics] that turned the doctors against addicts, that scared them out of treatment… As far as I like to think of it, the Narcotics men had really so scared the doctors that they abandoned the treatment of drug addiction, and therefore, there is no place for them to go. So they would be against addicts in the sense that professionally, they are denying a group of people treatment. “

Once I knew this history, I began to see the Michigan Medical Board investigation in a new context. The board was simply continuing the century-long tradition of criminalizing maintenance medications and the doctors who prescribed them. Even though addiction docs such as myself were reducing the demand for illegal opioids, enforcement saw our contribution to the opioid supply as the greater offense. Via telemedicine, I was making buprenorphine too accessible. 

Although changes in federal regulation meant that agents could no longer straight-out arrest doctors like me who prescribed medications for opioid use disorder, they could still get us when we broke small technicalities, an error easy to make in today’s confusing, regulatory patchwork. 

Such an approach framed a systemic problem—stigma against addiction treatment—as an individual failing: a doctor who is too loose with her prescription pad, that is, a modern-day script doctor. The goal? To scare doctors away from offering addiction treatment. They had also tried this with Marie. And, by and large, it worked. 

I emailed the president of the Michigan chapter of the American Society of Addiction Medicine (ASAM). Myself a member, I assumed they would be outraged that the medical board referred to buprenorphine as “prison heroin.” Who knew how many other doctors have been accused of the same thing? Once ASAM heard of this, surely they would start advocating to change the medical board’s opinion. 

Instead, the president emailed me back to recuse herself from discussing my situation, as she herself was on the Michigan Medical Board. Were addiction doctors themselves leading the charge against me? 

Later, I’d learned that Marie and [methadone pioneer Dr. Vincent Dole] felt the same betrayal, and were outraged by the medical community’s silence when regulators circumscribed their ability to offer effective treatment. A cruel loneliness settled into my bones; there was nobody to help shoulder the repercussions or to help guide me through this experience. If only I had a mentor, someone to help me forge this path through the wilderness. But, like Marie, I was doing this alone.

Excerpted from Chapters 1 and 3 of Mother of Methadone: A Doctor’s Quest, a Forgotten History, and a Modern-Day Crisis by Melody Glenn (Beacon Press, 2025). Reprinted with permission from Beacon Press.

You can read Filter‘s interview with Dr. Melody Glenn here.

Top image by Helen Redmond

The post A Doctor’s First Taste of the Methadone Clinic  appeared first on Filter.

In Mother of Methadone, the author invites readers into Nyswander’s personal and professional life and details the many barriers she faced during her career. Glenn tells the little-known history of how the Federal Bureau of Narcotics, the forerunner of the Drug Enforcement Administration, drove doctors out of addiction treatment with threats and imprisonment. These “narcotic agents” harassed and threatened Nyswander while she was researching methadone at Rockefeller University. She didn’t back down.

Glenn was looking for a woman mentor and found one in Nyswander. She weaves her story of becoming a certified addiction doctor with key moments in Nyswander’s life. As an emergency department physician, she treated numerous patients with opioid use disorder (OUD) and found it extremely frustrating. They never seemed to get well, and Glenn ended up “blaming the victim.” She admits to accepting many of the stigmatizing ideas about people who use drugs, and it bothered her.

Glenn’s journey to become certified involved many of the same obstacles Nyswander confronted decades earlier. How much have things really changed?

When she discovered the work of Nyswander, who had a tremendous amount of respect and empathy for drug users, it was a lightbulb moment. And there was a highly effective and safe OUD medication, methadone, that cut the rate of overdose deaths by over half.  Glenn also learned about buprenorphine. In the book there is a powerful passage where she gives a very sick patient buprenorphine, and a few hours later he’s feeling great and wants to leave the hospital. Glenn is elated.

Glenn’s journey to become certified in addiction medicine involved many of the same obstacles Nyswander confronted decades earlier. This makes Glenn wonder, How much have things really changed?

For two years she worked in an opioid treatment program (OTP, or methadone clinic), and witnessed how methadone changed her patients’ lives for the better. But at the same time the culture of cruelty made it difficult for them to stay in treatment. In the emergency department (ED), Glenn worked to create a modern addiction service that welcomes people who use drugs and offers OUD medication.

The book describes how she waits for hospital management to approve a press release promoting their upgraded addiction services. They never do. Glenn receives an email, “…are other ED’s in town doing this or are our teams the only ones. If so, does EMS [emergency medical services] know we are providing the service – will they bring all suspected OD/addiction patients to us because of the service? There is concern that if we announce this publicly we will become the city’s primary resource for substance abuse.”

Like that would be a bad thing! Glenn was furious.

This medical NIMBYism operates throughout the United States health care system. Hospitals love to promote their expertise in every field from liver transplant to sports medicine, but addiction? Not so much. It’s pure discrimination.

“I had to keep one foot planted in the grass roots of harm reduction, listening to users’ priorities and paying attention to their solutions.”

The final chapter of Glenn’s journey, perhaps the most important, involves her becoming a harm reductionist. In Tucson, she hooks up with Sonoran Prevention Works, and risking arrest, hands out sterile syringes and other harm reduction supplies.

“With the help of harm reduction, I would grow more comfortable walking the narrow line between working from within the system and from outside it,” she writes. “I did not want to squander my opportunity to advocate from within the house of medicine, as my professional credentials gave me access and credibility in a way that many people who use drugs did not have. But, to appropriately steer my actions, I had to keep one foot planted in the grass roots of harm reduction, listening to users’ priorities and paying attention to their solutions.”

Mother of Methadone should be read by physicians and other health care providers if they, like the author and Dr. Marie Nyswander, aim to practice addiction medicine with empathy and humanity. Filter’s interview with Dr. Melody Glenn has been edited for length and clarity.

Helen Redmond: How did you get interested in methadone and Dr. Marie Nyswander? 

Melody Glenn: In 2020 when I went to interview for a position as a physician at the methadone clinic, I realized I had some stigma about methadone, and I felt that it wasn’t just me; there was probably a whole cultural stigma against the medication in our society.

What’s the history of this? Has methadone always been stigmatized ever since its origins? So I went to the archives. I started looking in the New York Times Time Machine, in databases for old newspapers and medical journals. The stigma has been there since the beginning. Then I ran across an article in the Journal of the American Medical Association marking the 40th anniversary of methadone maintenance treatment. There was a picture of Dr. Nyswander and Dr. Vincent Dole, and the way it described her just really drew me in. She was very charismatic and charming and rebellious, and defied mainstream medicine to push addiction medicine forward.

Some people claim that methadone maintenance is just as influential and remarkable as the discovery of antibiotics, which I think is accurate. Overdose kills so many people every year, and here we have a very effective treatment—it’s just underutilized. Instead of opioid maintenance, treatments are abstinence-based and predicated on the idea that addiction is a moral failure or maybe even evidence of psychopathy. Nyswander and Dole believed that addiction was a medical disease for which they had a successful treatment. For a few years methadone rode this wave of success, and even though there was stigma there was also a lot of support, more support than I would say it has now. Nyswander had articles about her published in the New Yorker and then Vogue, and that’s just not something you see very often. 

“The founder of methadone maintenance hated the regulatory clinic system. So why don’t we listen to her?”

 

HR: How has Nyswander impacted your work as a physician? 

MG: She’s become a mentor. Despite the fact that almost a century spans between our careers, we share a lot of similarities. Neither one of us learned much of anything about addiction during our medical training, had many female mentors or intended to become an addiction physician, and we fell in love with methadone. We both found addiction medicine as a way to practice social justice and faced persecution from regulatory authorities because of it. We often felt like we were fighting the entire establishment all by ourselves.

So it just felt so rewarding and encouraging to see that someone else had been through this and thrived. Whenever I feel like I’m swimming upstream, I think of all that Nyswander went through and all she accomplished. She could very easily have given up, but didn’t, and the world is better because of it. Dr. Nyswander also helped me envision a world beyond methadone clinics. The founder of methadone maintenance hated the regulatory clinic system. She thought that any doctor should be able to prescribe it from any kind of clinic. So why don’t we listen to her?

HR: You mention the doctor-as-savior trope in the book. Can you unpack that?  

MG: I’m definitely trying to avoid it but it’s hard. If you yourself are not doing that, everyone else wants to put you into that role. When you look at medical stories, it’s so common to find ones in which the doctor comes in and saves the day. A community was lost until some visionary doctor appeared and guided them to become the hero. The doctor is effectively stripping the patients and communities of their agency.

It’s an inaccurate narrative because nobody works in isolation, and nobody’s success is solely attributable to their own hard work. I think it’s morally wrong. I believe the doctor’s role should be to listen, amplify and support the community in which they are working, offering some technical assistance along the way.  How can you make the world a better place without falling into the Savior role? Writing this book was a way for me to envision a different path forward, trying to really write the anti-savior narrative. In the end, harm reduction really provided those answers. Working with a group of people, you’re part of a team and they have expertise too. 

“The majority hate the overly strict rules, the carceral environment that effectively turns methadone maintenance into a form of chemical handcuffs.”

HR: In the book you document that Nyswander was a critic of the methadone clinic system. Can you outline some of her criticisms—and if you share them, having worked in an OTP? 

MG: I have a quote in the book which I think it’s so perfect, where Nyswander goes on this rant about the methadone clinic. She wants the medication to be delivered in every kind of clinic and hospital, and for any physician to be able to prescribe methadone— obstetrics, surgery—instead of leaving methadone to federally licensed clinics. 

Referring to her stable patients she said, “It’s just absurd for them to be stuck in a methadone clinic. I’ve had patients for 17 years. They’re better rehabilitated than you and I. There has been no drug use for 17 years and there is no reason in the world why they couldn’t have a month supply, six months supply. Many of my patients get four weeks of medication, they travel, no problem. It’s absurd to keep them in the clinics as part of keeping them isolated and keeping the finger pointed on them and reminding them of what unreliable people they are.”

I thought it was so beautiful how she put it. Methadone clinics are carceral, restrictive. Although I do have some patients who enjoy the structure of the methadone clinic, they appreciate the resources that are offered, I would say the majority have the opposite experience, where they hate the overly strict rules, the regulations, the carceral environment that effectively turns methadone maintenance into a form of chemical handcuffs. For the people who like the clinic, they can go, but the other people who are more stable really should have other options.

HR: Why are physicians so reluctant to work with people who use drugs, for example by prescribing buprenorphine? How can that change?

MG: I really think it’s a trifecta of stigma, overregulation and history. The 1914 Harrison act effectively removed addiction treatment from the purview of medicine. Doctors stopped treating patients and thought addiction is not a medical problem, it’s something better handled by incarceration or by behavioral health. Doctors haven’t learned anything about addiction. Medical schools weren’t teaching it and residencies weren’t either.

There’s overregulation. Back when there was the X-waiver, there were so many doctors who didn’t want to get waivered because they thought it must be really difficult and dangerous, and if there’s extra regulation I don’t want to be part of that. Now, more and more medical schools and residencies are teaching doctors how to start buprenorphine and methadone, they’re showing that there is treatment for addiction to opioids that in the past we just saw as really hopeless. But lots of programs are still neglecting to teach the philosophy of harm reduction, of meeting people where they are and supporting any positive change. Until we incorporate the harm reduction component, I think the stigma will remain. I also think medical institutions need to make sure that people who use drugs are at the table. 

“I went out to join harm reduction activists. They’re doing the things that need to be done instead of just pandering to the status quo.”

 

HR: Why were you willing to get arrested for handing out sterile syringes? 

MG: I got to this breaking point. I had a difficult situation with my hospital and the administrators. Despite all the work I had been doing to get doctors and the hospital onboard to improve the services we offer to people who use drugs, I felt like they would never actually care about the humanity of people who use drugs and never really offer what we need to actually get there all the way. I guess it was very slow going—small, incremental changes—and the longer our health care system took to implement change, the more lives would be lost.

I was sort of tired of waiting, so I went out to join some of the harm reduction activists who are taking these steps to make the world better for people who use drugs, even if it’s illegal. They’re doing the work. They’re doing the things that need to be done instead of just pandering to the status quo. I needed to do something that was going to make a difference. I started to work with a harm reduction organization and went out into the field to learn from them. I wasn’t trying to get arrested, and I was hoping that wouldn’t actually happen. I was just feeling so frustrated. It reminded me of the stories that I had heard of the early activists during the HIV/AIDS epidemic where they’re frustrated that the FDA is taking forever to approve antiretrovirals. And I thought of the movie Dallas Buyers Club and they just take it into their own hands.

HR: You got in trouble with the Michigan Medical Board. What happened? 

MG: I was working for this startup in California and living in the Bay Area. One of our nurse practitioners in Michigan had recently resigned and she had a handful of patients, and I refilled their prescriptions because I was worried if I didn’t they might relapse. We had an attorney who said it was fine, no problem. I was able to do telemedicine for these patients even though I had never seen them and I didn’t have a Michigan medical license. 

It was my first time prescribing anything in that state and it was just a bridge prescription. We could have them come to Ann Arbor another time, because lots of patients live very far away in the Upper Peninsula. It’s not easy for them just to drop everything and go to Ann Arbor and see a new provider. I was trying to look in the prescription drug monitoring program in Michigan, and it said you can’t because you don’t have a Michigan controlled substance license. 

“The Michigan Medical Board accused me of prescribing ‘prison heroin’—that’s what they referred to buprenorphine as.”

I didn’t know that I needed this “special license” to prescribe opioids in another state; nor did our attorneys. We quickly called the pharmacies and tried to cancel the prescriptions, but three of them had been filled. Then the attorney reached out to the Michigan Medical Board anonymously, self-reported, and asked is there anything we can do about this? The person at the Board said the fact that you’re self-reporting and you’re so concerned tells us there’s nothing to worry about. We only go after  the people who are really problematic, and so it’s okay. 

And then weeks later, coming up on my due date for my first baby, I get mail from the Michigan Medical Board. They accused me of prescribing “prison heroin”—that’s what they referred to buprenorphine as. I’m just like, what? How is this medical board using this terminology? Buprenorphine is the gold standard of treatment for opioid use disorder. I was absolutely shocked. 

There was a board investigation. It really dragged on and it was a stressful few months with a newborn. My husband and I were trying to buy our first home in Tucson and we couldn’t get the loan for the house until it was resolved. The lenders were like, “Nope, sorry, if you’re going to lose your medical license, we’re not giving you a loan.”

I ended up getting a fine. It’s considered a disciplinary action, so I have to report it on any kind of job I get, or when I renew my medical license. It will always be on my record. I think they did this to me just because they don’t like telemedicine, they found that it can make buprenorphine too accessible. It wasn’t really the three prescriptions.

HR: What are the two things that everyone needs to know about Dr. Marie Nyswander?

MG: Number one she was a badass who pushed addiction medicine forward time and time again, including the development of methadone maintenance, despite all the people and the institutions who tried to stop her. And two, she wanted to liberate methadone.

You can read exclusive excerpts from Mother of Methadone here.

Top image showing detail from the cover of Mother of Methadone: A Doctor’s Quest, a Forgotten History, and a Modern-Day Crisis (2025), featuring Dr. Marie Nyswander, courtesy of Beacon Press

Inset photograph of Dr. Melody Glenn by Helen Redmond

The post “Mother of Methadone”—Trailblazing and Stigma in Addiction Medicine appeared first on Filter.

In 2005, Mischley became one of the first people in his Michigan county to be prescribed buprenorphine for OUD. Buprenorphine has been a Food and Drug Administration-approved pain medication since the 1980s, but was only approved as a medication for opioid use disorder (MOUD) in 2002. Tighter regulations wouldn’t arrive until later, and Mischley’s initial prescription was for 64 mg—a dose that would be unheard of today. 

Mischley was on his mom’s health insurance plan, which was a good one because she had a government job with the United States Postal Service. Even that didn’t cover the entire prescription, leaving him with $200 or $300 in out-of-pocket costs each month.

“I told them that was too much, the cost was too much,” he said. “Everything was too much.”

But within a year his prescription was dropped to 32 mg, and things got easier for a little while.

Buprenorphine is a partial opioid agonist. It doesn’t affect people as strongly as full agonists such as methadone, which has been an FDA-approved MOUD for over 50 years, or unregulated opioids like heroin and fentanyl. Buprenorphine dulls the effects of full agonists, but on its own it can be enough to keep withdrawal at bay, which is all many OUD patients are looking for. And unlike methadone, which can only be dispensed at a clinic, buprenorphine can be picked up at a pharmacy like any other prescription. 

Mischley still had access to street-supply opioids that more readily produced a high, and found this challenging since he wanted to avoid them. But with a 32-mg buprenorphine prescription he managed to make things work by waking at the crack of dawn, taking two of his four daily pills and then falling back asleep. By the time he woke up again to actually start his day, the medication would have kicked in and would make other opioids feel like nothing if he took them. Which he found helpful.

“If I went and shot heroin after using Suboxone, it wouldn’t do anything,” he said. “It would just be like injecting water.”

The two MOUD tablets that the FDA approved in 2002 were Subutex, the brand name for buprenorphine, and Suboxone, which contains both buprenorphine and a smaller amount of naloxone. The Substance Abuse and Mental Health Services Administration (SAMHSA) endorsed the new MOUD up to 32 mg per day, which clinical evidence strongly supported as the maximum dose. The FDA, however, sent them onto the market with the following labeling:

The recommended target dose of SUBOXONE is 16 mg/day. Clinical studies have shown that 16mg of SUBUTEX or SUBOXONE is a clinically effective dose compared with placebo and indicate that doses as low as 12 mg may be effective in some patients. The dosage of SUBOXONE should be progressively adjusted in increments / decrements of 2 mg or 4 mg to а level that holds the patient in treatment and suppresses opioid withdrawal effects. This is likely to be in the range of 4 mg to 24 mg per day depending on the individual.

Over the next two decades, the impact of this would be that insurers generally won’t cover anything higher than 24 mg, and most prescribers won’t push them because they won’t consider higher doses in the first place.

But for many OUD patients, higher doses are what make buprenorphine effective.

Buprenorphine prescriptions above 24 mg have been linked to higher treatment retention, including in the period immediately after initiation. They’ve also been linked to a 50-percent reduction in emergency department visits and inpatient care. And over the past decade as fentanyl has taken the place of heroin in the unregulated drug supply, opioid tolerances are increasing and more people are finding that a maximum dose of 16 mg or 24 mg isn’t enough to keep them well. 

Centers for Disease Control and Prevention data for 2023

For those patients, the options for avoiding withdrawal are generally street-supply opioids, or methadone.

Health care providers who prescribe opioids for pain management use a framework called morphine milligram equivalents, or MME, to calculate what a patient’s dose for one opioid would correspond to for a different opioid. This doesn’t apply to MOUD, for a laundry list of pharmacological reasons starting with the fact that buprenorphine is a partial agonist and methadone is a full agonist; it’s a little like comparing apples to oranges. There is no universal equation that can say exactly what 24 mg or 32 mg of buprenorphine translates to in methadone. But for anyone taking more than 8 mg buprenorphine, standard practice would be to make the switch by abstaining for 24 hours, then starting with 30 mg methadone and going up from there.

Both methadone and buprenorphine are invaluable MOUD, but they are very different. Not everyone wants to go from a partial agonist to a full agonist, and vice versa. But the biggest reason someone struggling on a high dose of buprenorphine wouldn’t want to switch to methadone isn’t because of the medication itself, but because of the clinic system. Getting methadone for OUD usually means reporting to an opioid treatment program at dawn daily. Everything else in life—work, travel, illness—has to fit around that. Add to that the heavy surveillance, lack of privacy, long commutes for people in rural areas and notoriously punitive clinic culture, and it’s clear why for many people the biggest advantage of buprenorphine is that it can be discreetly picked up once a month at a pharmacy. 

Capping medication at a dose that doesn’t provide adequate relief is what pushes many patients to street supply, which is more dangerous than pharmaceuticals but easier and often more dignified to access. Research on extended-release injectable buprenorphine suggests that for people who inject opioids, doses higher than 32 mg could result in less use of street supply—if insurance weren’t a barrier.

In 2010 the FDA doubled down following its approval of Suboxone film (which has become the more recognizable formulation, compared to the tablets) stating that doses higher than 24 mg “have not been demonstrated to provide any clinical advantage.”

As part of the approval process, manufacturer Reckitt Benckiser Pharmaceuticals Inc stated that anything above 16 mg should be considered an exception.

“[T]here should be little difference in clinical effectiveness at doses between 16 mg and 24 mg in most patients,” Reckitt Benckiser advised. “When a patient expresses a need for a higher dose, consider the possible causes [and first] explore other alternatives. Also consider the possibility that the patient may be exaggerating symptoms to obtain additional medication for diversion.”

There has been no watershed moment for access to doses above 24 mg or even 16 mg—but there has been some progress.

Pre-pandemic data show that only around 3 percent of buprenorphine prescriptions were for doses above 24 mg, and only around 4 percent of prescribers were writing them.

“A lot of physicians and nurse practitioners have been afraid to write [prescriptions] for higher doses,” Dr. Edwin Chapman, an internal and addiction medicine specialist who has been treating OUD patients for 25 years, told Filter. “In their training, they were told for years that 16 mg was the target dose, 24 mg in special cases.” 

Patients and providers have been advocating for years to remove the additional layers of bureaucracy and surveillance that come with prescribing buprenorphine for OUD, like urine drug screens and extra steps required for insurance approval. In 2023, the Drug Enforcement Administration eliminated the X-waiver, a federal requirement that had been created specifically for buprenorphine and had severely restricted access to prescriptions. Telehealth prescribing has also now been expanded, building on momentum that began during the COVID-19 pandemic. There has been no watershed moment for access to doses above 24 mg or even 16 mg—but there has been some progress.

In 2023, Chapman and dozens of other stakeholders presented the FDA with their case for doses over 24 mg having benefits for many patients, at no added risk. The concept gained traction with federal agencies, and in December 2024 the FDA made a public recommendation that manufacturers of buprenorphine products that dissolve under the tongue (meaning tablets or film, but not the longer-acting injectable formulations) update their labeling.

“[N]either 16 mg/day nor 24 mg/day should be interpreted as maximum dosages,” the FDA stated.

The agency advised removing references to a “target dose,” and noting that doses above 24 mg “have not been investigated in randomized clinical trials but may be appropriate for some patients.”

In a letter explaining the decision to prescribers, Dr. Marta Sokolowska of the FDA’s Center for Drug Evaluation and Research noted that the agency was aware that insurers had been restricting access to higher doses as a consequence of the language previously used on the labeling.

In 2023, one of Chapman’s patients overdosed after United Healthcare capped his buprenorphine coverage at 24 mg. The patient survived—and the story made the front page of the Washington Post. Since then, United has covered Chapman’s patients up to 32 mg without issue. But he still has to go through the process of obtaining prior authorizations. And months after the FDA formally clarified that buprenorphine has no maximum dosage restrictions, this hasn’t changed. 

“8-2MG” refers to a standard Suboxone strip containing 8 mg buprenorphine combined with 2 mg naloxone. Insurers will often cover prescriptions up to three strips (24 mg buprenorphine) per day, but not four.  

“I don’t know if it’s just because of me or whether other doctors have difficulty getting above 24 mg with United Healthcare,” Chapman said. “But the point is they’re still saying 24 mg [is the limit].”

Like every other extra bureaucratic hurdle attached to buprenorphine, prior authorizations are associated with decreases in treatment retention.

The American Medical Association, one of the organizations that pushed the FDA to revise its labeling recommendation, has urged insurers to update their policies accordingly. The FDA is also currently supporting a high-dose buprenorphine study in collaboration with the Department of Veterans Affairs. But experts reached by Filter say it could be a year or more before the FDA recommendations begin to have real-world impact for most patients. Meanwhile, many will lose access amid the arrival of President Donald Trump’s “big, beautiful law” and its $1 trillion in cuts to Medicaid. Of the nearly 2.5 million people in the United States who filled buprenorphine prescriptions between April 2020 and March 2024, approximately 48 percent used Medicaid to do so at least once.

Elimination of the X-waiver has not yet done much to actually increase the number of health care providers prescribing buprenorphine. And, despite the updated labeling recommendations and the removal of the X-waiver, some states also maintain their own restrictions that impede access. 

“I’ve had people tell me not even to send the second prescription because they know they can’t afford it this month.”

Dr. Jared Matthews, an addiction medicine physician in Tennessee, described the state as “a really great example of what not to do.”

Tennessee has taken some recent steps to increase access to 24 mg doses of buprenorphine, but in practice the state effectively caps prescriptions at 16 mg.

“Administrators with the actual Medicaid program, most of their higher-level executives are physicians,” Matthews told Filter. “They are well aware of what the medical evidence tells them they should be doing … yet when they take these proposals to their political leadership, the answer is always No.” 

So for patients who require a higher dose, Matthews writes two separate prescriptions: one for a 16 mg dose covered by Medicaid, and one for whatever remaining number of milligrams the patient needs, which they must pay for out of pocket. Each additional 8 mg can cost upwards of $200 per month.

“I probably have no less than 100 patients where 16 milligrams is not adequate to control the signs and symptoms of their opioid use disorder,” Matthews said. “I’ve had people tell me not even to send the second prescription because they know they can’t afford it this month.”

In Kentucky, prescribing over 16 mg is restricted to advanced practice registered nurses certified in addiction medicine. The state also doesn’t allow buprenorphine to be prescribed for pain management, only OUD.

“Indiana allows it for pain management,” Dr. James Murphy, whose clinic straddles the border between the two states, told Filter. “Federally, it’s allowed. The Veterans’ Affairs nationally actually has Suboxone listed as one of the choices that we can use for chronic pain management. Yet in Kentucky that would be considered illegal.”

Murphy treats some pain patients with buprenorphine, or with methadone; many have complex needs wherein OUD and chronic pain overlap. As a result of the outdated regulations, he fields a lot of calls from pharmacies and insurers alleging that his patients’ doses are too high. But for his patients across the river in Indiana, he’s able to more readily prescribe the doses they need.

“What is it about a river or a line or a border that makes the patient different?” Murphy asked. “The patient with chronic pain and opioid use disorder is the same in Kentucky as [in] Indiana.”

“Red flags” are triggered by activity the DEA considers suspicious.

Buprenorphine is regulated under Schedule III of the Controlled Substances Act. As with other opioid analgesics, and certain other pharmaceuticals like benzodiazepines, buprenorphine prescriptions are tracked by the DEA through a nebulous web of proprietary algorithms known as prescription drug monitoring programs (PDMP). “Red flags” are triggered by activity the DEA considers suspicious.

Providers, for example, can trigger red flags by writing a lot of prescriptions for higher doses. Pharmacists are required to check for these red flags, and can be held liable for filling prescriptions the DEA determines they shouldn’t have. 

Patients, meanwhile, can get red-flagged by paying for prescriptions in cash—which data suggest is the most common method of payment for buprenorphine prescriptions above 24 mg.

“Sometimes it’s difficult for patients to even fill a buprenorphine script,” said Jonathan Larsen, a public health law expert at Temple University. “If a pharmacist is feeling uncomfortable about [dispensing] buprenorphine because it might raise red flags.”

A secret shopper study conducted in 2022 found that in Tennessee, the majority of pharmacies would likely refuse someone trying to start treatment with buprenorphine. Researchers called 183 pharmacies, across all but one of the state’s 95 counties, asking to fill a prescription for a new patient—and 53 percent of the pharmacies said No. Many had caps on the number of buprenorphine patients they were allowed to serve, as well as waiting lists for when space opened up. Many pharmacies didn’t stock buprenorphine at all, citing pharmacist discretion as one of the main reasons.

Murphy has written prescriptions that patients were unable to pick up because pharmacists refused to fill them. This is a widespread barrier. Fear of being raided and shut down keeps many pharmacists from filling higher-dose buprenorphine prescriptions, even if the insurer has agreed to cover it.

One doctor stopped seeing Mischley after a urine drug screen indicated he’d used marijuana.

These days, Mischley’s prescription is for 24 mg and that’s been working well for him. But over the past two decades, heavy surveillance and aura of illegality around higher-dose buprenorphine has cut off access to his prescription multiple times.

One doctor stopped seeing him after a urine drug screen indicated he’d used marijuana. This was before both medical and adult-use legalization in Michigan, but this didn’t seem to be where the concern was coming from.

“[The doctor] said since his license was federal,” Mischley said, “and [marijuana was] illegal federally, he couldn’t risk that.”

Around 2012, the doctor prescribing Mischley’s buprenorphine by that time was investigated by the DEA, and his practice subsequently shut down. This doctor also issued medical marijuana cards, and apparently the DEA felt he issued too many of them.

Mischley is on his seventh provider. Like paying in cash, frequently changing doctors can be a DEA red flag, too.

Top image (cropped) via Drug Enforcement Administration. First inset graphic via Centers for Disease Control and Prevention. Second and third inset graphics via Dr. Edwin Chapman.

R Street Institute supported the production of this article through a restricted grant to The Influence Foundation, which operates Filter. Filter‘s Editorial Independence Policy applies.

The post The Case for Higher-Dose Buprenorphine appeared first on Filter.

A new study published in the Journal of Substance Use explores people’s challenges in accessing these life-saving drugs—including inaccessible clinic locations, mistreatment by staff, insufficient doses, confusion over dosing schedules and a host of other obstacles. 

Together, these challenges made it hard for people to stay in treatment, with the requirements around MOUD causing, as one participant put it, “more stress than you know.” Many participants felt forced to take treatment into their own hands, supplementing their prescribed doses with heroin or methadone obtained from unregulated sources.

The majority of participants were either unable to start treatment or left their program early. 

The researchers interviewed 36 people seeking methadone or buprenorphine treatment in Chicago, most of whom were Black or Latino. Roughly one-third of the participants got into a treatment program and stayed in it, but the majority were either unable to start treatment or left their program early. 

Methadone in the United States generally requires a strict schedule of daily in-person visits to the clinics (also known as opioid treatment programs) that have a near-monopoly on dispensing the tightly regulated drug. This in itself, together with the carceral, punitive nature of many clinics, represents a major barrier to care—and explains why advocates have called for the methadone clinic system to be abolished in favor of pharmacy pickup, as practiced in other countries.  

Within the confines of the US clinic system, the study showed how transportation is a big obstacle.  

“Even in a place as busy as Chicago, methadone clinics are few and far between, and they have very limited dosing time,” lead author Dr. Jodie Dewey, a research scientist at Chestnut Health Systems’ Lighthouse Institute, told Filter.  

When having a truly local methadone clinic is rare, the cost of securing transportation for daily visits adds up quickly, especially for patients who have to take multiple buses or call an Uber. Dewey estimates that a typical round-trip clinic visit in Chicago costs $10 to $20. In rural areas, it would likely be far more. 

But perhaps even more costly is the time involved. Long travel times to clinic locations, combined with unpredictable wait times, imposed significant burdens on people who may have jobs, families and other pressing responsibilities. And then there are unpredictable waiting times at the clinics themselves.

“You just don’t know how long it’s gonna take,” Dewey explained. “Are you gonna get to the clinic and it’s gonna take five minutes? Or are they backed up and you’re gonna be waiting for two hours?”

“People don’t wanna go to [those] clinics because they don’t feel respected. It’s a very policed kind of environment. They don’t feel safe.”

Many participants who made it to clinics experienced negative encounters with staff that discouraged them from participating in treatment. They described being spoken down to, being denied medication for being late by minutes, or being “disciplined” for missing doses—punitive policies that led some to drop out of treatment altogether.

While not all clinics were structured this way, participants who received treatment in rigid, punitive environments often felt discouraged from coming back. 

“People don’t wanna go to [those] clinics because they don’t feel respected,” Dewey said. “It’s a very policed kind of environment. They don’t feel safe.”

Others reported receiving dosages too low to manage withdrawal symptoms, and being unable to increase them quickly due to rigid clinical procedures.

“It could take days and maybe even weeks to move people between their milligrams,” said Dewey. “That might just take too long.”

To bridge the gap between doses or to make up for missed visits, some patients turned to heroin or “diverted” methadone. One woman described keeping extra methadone doses in her fridge because “it takes the edge off” when she can’t make it to the clinic. One man continued to use heroin to supplement his 20 milligram dose of methadone, which he knew from experience “wasn’t gonna hold me, because it’s not as potent.”

Buprenorphine (Suboxone) is often hailed as a solution to these problems. Burprenorphine dispensing isn’t clinic-based, and it is administered in two-to-four week increments of take-home doses, eliminating the need for daily travel. However, the participants who were prescribed buprenorphine described experiencing a whole new set of problems, largely due to the timing of these self-administered doses.

“You have to wait till your withdrawal symptoms are so bad you just almost can’t take it,” Dewey explained. “It’s not just uncomfortable—it can be excruciating.” 

One woman tried to “contact the pharmacy to see if I had any more refills and they said I didn’t, so I guessed I wasn’t supposed to take any more.”

The ubiquitous presence of fentanyl in Chicago’s drug supply made determining the right time to take buprenorphine particularly challenging. Several participants noted that fentanyl, as compared to heroin alone, dramatically altered when and how they experienced withdrawal. As one explained, “[Y]ou have to actually be, they say, without heroin for 24 to 48 hours [before dosing], but with everything they puttin’ on it, it got to be a longer wait.”

Once the initial 30-day prescription ran out, many people weren’t sure how to proceed. One woman tried to “get in contact with the pharmacy to see if I had any more refills and they said I didn’t, so I guessed I wasn’t supposed to take any more.”

Without clear guidance from medical providers or follow-up communications to confirm next steps, the study reported that running out of take-home doses was the “biggest challenge to staying in treatment” for people taking buprenorphine. 

Coupled with the confusion around when to dose and how much to take, these challenges indicate that buprenorphine’s hands-off delivery is not currently a perfect alternative to methadone’s clinic system. Better guidance at critical points throughout the treatment process, from honing an initial dosing strategy to transitioning off the medication, could help many more people experience fuller benefits. 

Despite federal efforts to loosen MOUD regulations in recent years—including take-home doses for methadone and telehealth appointments for buprenorphine—the study illustrates how many patients still find the processes disempowering and opaque. 

Dewey emphasized that behaviors many health professionals would label as “non-compliant” should be taken as understandable responses to systemic issues, not mistaken for lack of interest in recovery.

“There’s all these barriers that seem really simple—like these transportation issues, or just the way someone is treated in a clinic,” Dewey said. “Something as simple as, you know, you didn’t acknowledge me, you didn’t humanize me. Nobody wants to feel that way.”

Dewey emphasized that behaviors many health professionals would label as “non-compliant,” such as supplementing doses with heroin or leaving treatment early, should be taken as understandable responses to systemic issues, and not mistaken for lack of interest in recovery.

“People are heavily engaged in their recovery, but it’s just not working 100 percent for them,” Dewey said. “They have to find these other workarounds to keep themselves comfortable enough so they can stay and remain engaged.”

Being forced to resort to those workarounds, however, makes it difficult for many people to achieve their individual goals. Leaving treatment also often means losing access to a broader web of support surrounding treatment programs, like housing referrals, case management and access to food or health care.

By centering people’s experiences with MOUD access and highlighting some of the specific challenges they face, Dewey hopes that her research will guide improvements to treatment systems.

“When people are having challenges … let’s meet them where they’re at and figure that out,” she urged. “How do we deliver better systems? How do we deliver treatment that people need in a way that makes sense?”

That shift will require new policies, but also a cultural change in how providers view the people they serve—not as problems to be managed, but as partners in care.

“We’re not just passing paperwork, we’re not just signing off on things,” Dewey said. “We’re working with people. And hopefully you’re there because you care about people.”

Photograph by Helen Redmond

The post People Seeking Methadone or Bupe Face “More Stress Than You Know” appeared first on Filter.

Some background: Opioids like fentanyl, heroin and methadone are full agonists. Basically this means they have a strong effect. On the other end of the spectrum, you have opioid antagonists, such as naloxone—these kick the aforementioned full-agonist opioids off your receptors, which is why naloxone is great for reversing overdose.

Opioid overdose causes respiratory depression, and the right dose of an antagonist clears out just enough of the full agonist to let someone start breathing on their own again. But an excessive dose—one that doesn’t leave enough of the full agonist behind—puts the person into withdrawal. But all at once, rather than over the course of hours, and trying to make the symptoms go away is difficult and dangerous. This state is called precipitated withdrawal. It sucks.

Buprenorphine, AKA Suboxone or just “bupe,” is a partial opioid agonist. This means it’s a very effective MOUD for some people, while for others it’s just not enough. But it also means that bupe can precipitate withdrawal, too, if someone takes it while they still have too much of a full-agonist opioid in their system.

Over my many years of using many different opioids, I’ve adapted the Bernese method to my daily life.

The traditional way of getting on bupe is that you have to wait until you’re way into regular withdrawal before you start taking it, to avoid precipitating withdrawal. And if you get desperate and take it too soon, or a doctor misgauges how long you should wait, you end up precipitating withdrawal anyway.

There are a small number of alternative methods that are much more humane, the best known being microdosing through the Bernese method. This basically involves starting with tiny doses of bupe that you gradually increase while you continue using your usual opioids, and doesn’t require you to be in a miserable state to get started. It’s a short-term thing, just for the period of transitioning away from the full agonist. But over my many years of using many different opioids, I’ve adapted the microdosing protocol to my daily life.

This works for me for two reasons. First, I’m semi-regularly in situations where I need to switch over fully to bupe for a few days—family gatherings, that type of thing. Second, my tolerance is pretty high. If it weren’t for those two things, I wouldn’t be doing this. Nothing in this article is medical advice, just in case that wasn’t obvious.

Let’s say I’m using a bundle—10 bags—of fentanyl per day. (Or rather, fentanyl plus whatever else ends up in there these days.) And let’s say in 10 days I’m going to get on a plane to visit family, and I’ll need to get by on just the bupe until I’m back home.

I can’t just switch over from fentanyl all at once. So at T-minus 10 days I’d get one of my 8-mg Suboxone strips and take just a tiny piece—about one-tenth of the strip. And I’ll take that on top of my 10 bags. At T-minus nine days, I take two of those pieces, and drop my street supply intake down to nine bags. At T-minus eight days, three-tenths of the Suboxone strip and eight bags of dope, and so on and so forth.

Once a day, about three days a week, I take 1 mg of Suboxone.

This is not a perfect system. Of the dozens of times I’ve done this, only one single time did I manage to pull it off flawlessly; if you graphed it, with bupe going up and the fent going down, it would have made a perfect X. Bernese himself would have given me a kiss. The Bernese method is actually named after Bern, Switzerland, but that’s not the point.

So even though I’ve been doing this over a decade, I still almost always end up with some withdrawal symptoms here and there. What I’ve found makes the process smoother is to keep a low level of bupe in my system at all times, not just special occasions. 

Once a day, about three days a week, I take 1 mg of Suboxone. I’m just eyeballing one-eighth of a strip as I tear it off, so each piece is probably between 0.75 mg and 1.25 mg.

Despite the concern about using bupe too soon after using a full agonist like fentanyl, it’s never made that much difference whether I take the bupe before or after I start using fentanyl for the day—but this is because I use a lot of fentanyl. For someone using smaller quantities, or a less-potent opioid, 1 mg of Suboxone could easily throw them into vicious precipitated withdrawal if they take it too soon. 

Usually I do my two-bag wakeup dose of fentanyl first thing in the morning, and then see how I’m feeling. If I’m feeling good, and it’s one of the three-ish days a week I’m microdosing, I’ll take the little piece of bupe right then and get it out of the way—because while I appreciate bupe as a useful tool, and know what a literal lifesaver it is for so many people, personally I kinda hate it. I don’t get any effect from it, and it often dulls the fentanyl. So I have to keep an eye on whether my fentanyl use goes up as a result of the microdosing, and sometimes it does. But overall this has been manageable, and the constant microdosing seems to help acclimate my brain to the partial agonist—both physically and mentally.

Image via New Mexico State Legislature

The post Why I Microdose Suboxone, While Continuing to Use Lots of Fentanyl appeared first on Filter.

This will remove a significant barrier for many patients. However, six months’ worth of medication will not be enough for patients without in-person access to a provider, and telemedicine itself is not feasible for many of the patients at risk. 

Buprenorphine, commonly referred to by the brand name Suboxone, is one of the three Food and Drug Administration-approved medications for opioid use disorder (MOUD), and one of the two shown to reduce overdose risk. Under the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, buprenorphine could previously be prescribed only after an in-person visit. During the pandemic lockdowns, as patients and providers increasingly turned to telehealth, it became evident that waiving the requirement was feasible and badly needed. In 2023, the number of buprenorphine prescriptions dispensed in the United States—more than 15 million each year—was about the same as it was pre-pandemic, despite the obvious need for expanded access.

For this reason, during the pandemic buprenorphine was temporarily allowed to be prescribed via telemedicine. The DEA final rule making it permanent was originally scheduled to take effect February 18, but that changed after President Donald Trump was inaugurated and put a freeze on federal rulemaking procedures. On February 14, it was formally pushed back until March 21.

The temporary rule still won’t expire until the end of 2025 (by which time it was assumed that many pandemic-era barriers would have eased) so it remains unaffected. The public can still submit comment on the rule until 11:59 pm on March 18. 

Federally Qualified Health Centers are uniquely positioned to address the overdose crisis, but are limited by chronic understaffing and insufficient resources.

Nearly 20 percent of adults diagnosed with OUD are uninsured, and of that group 25 percent are living in poverty. The expanded telemedicine rules represent real progress, but cannot replace in-person care and cannot be implemented in isolation. 

On January 16, the same day the rulemaking was announced, JAMA Network Open published a study showing that in 2023, community-based health clinics serving at-risk populations were providing MOUD to fewer than one in four eligible patients. Of the three FDA-approved MOUD, methadone remains confined to the clinic system and naltrexone is associated with increased overdose risk, so there is a pressing need to increase access to buprenorphine. 

More than 32 million people in the US rely on Federally Qualified Health Centers (FQHC), commonly known as community health centers, for their medical care. FQHC are primarily located in medically underserved communities and serve patients regardless of immigration status, insurance coverage or ability to pay.

These centers are uniquely positioned to address the overdose crisis, but are limited by chronic understaffing and insufficient resources, and by the fact that many medical providers never receive training that covers equitable care for patients with substance use disorder.

The JAMA study highlights how our most vulnerable populations, who already face multiple barriers to health care, are being left behind even as we expand use of telemedicine. Among other particularly troubling disparities, the study found that non-white FQHC patients and those experiencing homelessness were the least likely to access MOUD.

Investment in FQHC would not only improve in-person care, but also improve telemedicine.

To truly address the overdose crisis, policymakers must pair telemedicine expansion with robust investment in FQHC. This means:

First, a significant increase in funding for FQHC providers to receive training and education specific to buprenorphine. Not just prescribing it, but the full spectrum of OUD care, from initial screening to long-term recovery maintenance.

Second, an expansion of other on-site behavioral health services. Many people who use FQHC services, particularly those with more complex medical needs, require in-person care coordination that is only feasible to access if it’s located within their community. 

These investments would not only improve in-person delivery, but also improve telemedicine. After all, adequate staffing levels and more comprehensive care being delivered in-person would have a positive effect on the virtual services, too.

More than 1,000,000 people in the US have died of overdose since the CDC began tracking those deaths in 1999. The crisis demands a dual approach—expanding telemedicine access while simultaneously strengthening our ground-level treatment infrastructure. Only by investing in both can we bring lifesaving treatment within reach of all patients who want it, not just the patients with the resources to access it easily. Otherwise we risk perpetuating a two-tiered system that expands telemedicine access for some, while leaving others further behind.

Image (cropped) via Everett, Washington

The post Telehealth Bupe Is Expanding. To Take It Further, Fund Community Clinics. appeared first on Filter.

The answer is an unequivocal yes, when it comes to Whiteout: How Racial Capitalism Changed the Color of Opioids in America (University of California Press, 2023), by Helena Hansen, David Herzberg and Jules Netherland. Through a critical lens of racial capitalism, the authors dissect licit and illicit opioid use and access, from past to present.

In the first chapter, “Pharmakon of Racial Poisons and Cures,” Hansen lays out their thesis: “We examine the unspoken but determinative Whiteness of opioids, to make the ways that Whiteness works in drug policy and treatment visible. Here, whiteout refers to the use of imagery to hide or cover the inner workings of segregation in drug policies and healthcare industries.”

You’ll find sentences that need underlining on every page. 

The authors present an original analysis that will persuade many readers to reevaluate their beliefs about the intersection of Big Pharma, drug prohibition and for-profit health care. For example, in the chapter “Oxycontin’s Racial Precision” they write, “Purdue Pharmaceuticals’ betrayal turns out not to be about the betrayal to all consumers; rather, it is about the breach of an implicit promise to uphold a safe, affluent white zone of clinical narcotic consumption, segregated from illegalized and hazardous racially ‘other”’street markets.” Bam! This provocative assertion should trigger many debates.

Whiteout is written by three uniquely qualified individuals whose research and writing overlap. As a result, the book includes an astonishing amount of material backing up their assertion that Whiteness is foundational. You’ll find sentences that need underlining on every page. Their recent webinar, moderated by historian Robin D.G. Kelley and sponsored by Haymarket Books and the Drug Policy Alliance, is also recommended viewing.

Jules Netherland is a sociologist and policy advocate. Her experience ranges from working in a soup kitchen with Franciscan monks to buprenorphine researcher to policy advocate. Her harrowing account of what it took to pass a stripped-down medical marijuana bill that would help few patients is required reading. It’s an illuminating example of the power of Whiteness to shape drug policy even when anti-racist activists fight hard to prevent it. Netherland writes, “The entry of suburban moms and their children changed the debate and what was possible for medical marijuana legislation …’white innocence’ seemed to be what legislators and the media found most moving.”

David Herzberg is a historian who writes, “Remembering forgotten things is what historians do.” Among his many contributions to the book is explaining how Whiteness has always influenced access to opioids. From Chinese opium use to the era of Jim Crow to today, he unpacks the “racialized drug/medicine divide.” He includes striking side-by-side quotes from politicians, police and pundits that reveal almost every era has had a prescription drug crisis. We just forgot.

Hansen is an addiction psychiatrist and anthropologist. She is an astute observer and interviewer. And her experience working inside opioid treatment programs provides invaluable insight through her witnessing of the effects of Whiteness in real time. Her hilarious story about a white buprenorphine patient from Long Island speaks volumes about privilege: “She pulled her car into the taxi stand at the hospital entrance and called the clinic staff from her cell phone. ‘I’m right downstairs and there is nowhere to park. Could you just bring down my script?’ No one ever did.”

Dr. Hansen spoke with Filter about the system of Whiteness, and its pernicious impacts on health care and access to lifesaving medication.

Helen Redmond: In your book, you discuss your experiences working in a New York City public hospital, with a compelling analysis of race, class and medication for opioid use disorder. Can you tell us about who gets prescribed buprenorphine and who goes to a methadone clinic?

Helena Hansen: So first, I’ll describe the cognitive dissonance when I went to the methadone clinic, which was a requirement of anyone training in addiction medicine or addiction psychiatry. The methadone clinic was everything you might expect of a New York City public hospital. We had a bunch of underinsured, publicly insured and uninsured patients, many of whom were referred to the clinic by drug courts and parole officers. So they were mandated to treatment in many cases.

A lot of them had unstable housing. And it was clear that the clientele was primarily Black and Brown, and any white patient who happened to get into the mix was clearly down on their luck.

It was the kind of clinic that had signs with all of the rules posted everywhere. There was a lot of enforcement of rules, security guards right at the front of the line with separators and dividers to keep everyone in check. The nurse was behind bulletproof glass. Patients would have to take methadone in front of the nurse, who would inspect their mouth right after swallowing it to make sure they were taking it—meaning not hiding it in their cheek to sell on the street afterwards.

“The contrast was remarkable. I began asking, how did this happen? These are patients that supposedly have the same clinical disorder.”

I would sit there and observe people taking their methadone doses. There was unannounced urine testing. The person had to be accompanied by a same-sex security guard or staff member, to make sure that they weren’t sneaking someone else’s urine into the sample bottle. It was highly controlled and had a carceral feel. It just didn’t feel like it was a health care space.

That was in sharp contrast to the brand-new buprenorphine clinic that I saw get started. This was just after buprenorphine had been approved by the FDA for office-based treatment of opioid use disorder. It was fascinating to see the clientele that the clinic attracted; it was largely white. They were people who had graduate degrees, who had really nice kinds of jobs—journalists and managers. They were people who you would not find in any other clinic in a large city public hospital.

The contrast was really remarkable. That’s what actually tipped me off and led me down this path that became a partnership with Jules Netherland and David Herzberg. I began asking, how did this happen? These are patients that supposedly have the same clinical disorder.

I began to pay attention to how people learned about buprenorphine, and how they got referred for it instead of methadone. And even though these two clinics were in the same building, two floors away from each other, they were two completely different worlds. The people coming to the clinic had gone online and done their research about where to find buprenorphine. They’d learned about it through internet ads or a private doctor. These people were really educated, really well-connected, and some had private insurance. They were in a totally different league.

How do you define Whiteness and how it operates? 

What I mean by Whiteness—my coauthors and I use the term much more often than we refer to white people—is that Whiteness is more than the color of someone’s skin. Whiteness is a whole system.

If you find yourself in a system like this, it doesn’t matter whether you claim to be a white person or not, you’re falling into a system that has implications that are beyond your control.

“Systems of Whiteness, we argue, are harmful to everyone.”

For instance, I’m not somebody who, if you were to look at me, would be considered white. And so I cannot just declare myself to be white and get so-called benefits of Whiteness. But neither can someone who could claim to be white, based on their heritage and their appearance, decide, “I’m unilaterally going to just not do anything that takes advantage of my white status in society.”

Whiteness is a social system by which people are regulated and channeled into a health care system that is stratified. Systems of Whiteness, we argue, are harmful to everyone.

I began to track Whiteness and how that works within our health care system and within pharmaceutical marketing. In interviewing pharmaceutical executives and addictions researchers, I discovered that historically, the way office-based buprenorphine evolved was when federal legislators and pharmaceutical executives started paying attention to the approval of Oxycontin for use in moderate pain in 1996. They were tracking the evolution of a whole new group of people who were dependent physiologically on opioids and who, in their minds, weren’t suitable for methadone treatment programs.

And you can actually find that language in the Congressional Record. They didn’t mention white people, but they referred to suburban youth and suburban communities. We know in the US that’s coded language for largely middle-class white people. So it is race and class bound together.

We realized that we were excavating a whole system of Whiteness within pharmaceutical development and marketing, and also in relation to drug policy and the health care system.

“It was no accident that the buprenorphine clinic was so distinct by race and class.”

It involves pharmaceutical companies with the most expensive new products that are patented, so they have exclusive rights to sell that product at whatever price the market will bear. Usually the initial clientele is a white, middle-class-to-affluent clientele that can buy the medication.

It was no accident that the buprenorphine clinic was so distinct by race and class. It was originally designed for people who could pay with private insurance or out-of-pocket. The last national study showed that white Americans were three-to-four times as likely to get buprenorphine as Black Americans, and the most common form of payment was out-of-pocket, followed by commercial insurance. And it’s very, very thinly veiled in the Congressional Record when they were debating legalizing buprenorphine for office-based treatment.

They managed to get federal law passed that reversed 80 years of federal prohibition of private doctors prescribing opioids to people dependent on opioids for addiction treatment. Since 1914 and the Harrison Act, there have been a lot of federal laws that have strongly discouraged and then prohibited doctors from doing that.

Methadone maintenance was just a very partial exception. It was this moment in the late ‘60s, early ‘70s, when in the midst of race riots and white flight from center cities, there was a perceived heroin problem. Methadone was one of the things Nixon rolled out in the War on Drugs. Methadone was a way to pacify or address that, in addition to arrests and incarceration. So it has this whole other racial biography.

How did Purdue Pharma’s marketing of Oxycontin intersect with Whiteness?

Purdue Pharma, they were just doing good capitalism and delivering for their shareholders as promised. They’re trying to market a product, so that’s where Whiteness comes in. It’s not just any individual person’s status as a white person, it’s actually a system that many of us are forced to participate in.

With regard to selling Oxycontin, they knew who their clientele was. They knew that they were going to be selling a very expensive product, and the people who were going to buy that product would have nice private insurance or be able to pay out-of-pocket.

There was a subset of working-class people with workers comp. insurance that would pay for these new opioids. So I want to make it clear that from the get-go, there was a sub-group, particularly the laboring classes in construction and mining, who had insurance that would pay. Purdue Pharma was also looking for people who did work that left them with a lot of injuries and needed treatment for pain. So from the beginning, it wasn’t only affluent people.

They also knew that they were going for deregulation of an opioid in a society that has had incredibly prohibitionist policies for a century. And they knew that one reason for those strong prohibitionist policies had been the non-white races [to which] the media and politicians had been attributing addiction for a century. So they knew that the white color and relative affluence of their clientele would be a helpful antidote to push deregulation of an opioid in a very drug-phobic society.

“The political compromise in the 1990s was not to expand disability benefits for people in pain, but to allow the private market to be liberalized.”

My coauthor David Herzberg really adds nicely to this, which is that there was a whole politics of pain happening at the time. It’s no accident that in the 1990s, there was an epidemic of pain declared. And there were a number of organizations, starting with the VA hospital system, that were calling attention to the under-treatment of pain.

At the same time there’s also a raging political struggle around Social Security disability benefits. So left-leaning people wanted to liberalize benefits and be much more cognizant of pain as a source of disability, and free up more public resources to support people who are disabled by their pain—versus right-leaning people, who did not like the idea of expanding public benefits and saw a danger of indulging too many “welfare queens” who were claiming to have pain.

So the political compromise in the 1990s was not to expand disability benefits for people in pain, but to allow the private market of treatment for pain to be liberalized, including the new opioids. That’s the role Whiteness played early on in the politics of opioid marketing. Not only did they know who their market was, who could afford it, they also knew how to get around the regulations and take advantage of the privatization of the pain problem.

Rep. Donald Norcross (D-NJ) has a bill called the Modernizing Opioid Treatment Access (MOTA) act. It would allow patients to pick up methadone at a pharmacy—bypassing the clinic system, which Norcross calls a cartel. But I have a serious problem with the fact that MOTA only allows board-certified addiction physicians and psychiatrists to prescribe methadone. In line with your analysis, it seems that white middle-class people would be able to escape the carceral clinic system—because of Whiteness. What do you think?

I think you said it beautifully. I mean, that’s exactly it, relying on the same tiny group that does buprenorphine prescribing to do methadone prescribing.

I’m an addiction psychiatrist. I know that there are very few of us, and that most of us are in private practice. I can name the number of Black addiction psychiatrists in the country on one hand. If you’re a hyper-specialist, you know who your clientele is going to be: You’re choosing a rich clientele, largely white, just by specializing. That’s what you get in a privatized health care system. So this is not a solution to the inequalities that we’re facing. It’s the same little exclusive group that currently gets buprenorphine that will pick up methadone at a pharmacy with this legislation.

You have to overhaul the way the system works. If Norcross is serious about equity, he would do what the people testifying at the NASEM workshop on methadone regulation last March were talking about. Put methadone into community organizations. If you want more LGBTQ people to have access to methadone, put it into LGBTQ community centers. You make sure that the kind of people those centers hire are able to prescribe it, that’s the way you do it. You don’t go to hyper-specialists.

Do you think that ending the drug war and legalizing and regulating all drugs would eliminate racial disparities in drug treatment?

That’s a really nice question. If what you mean by ending the drug war is that you legalize or at least decriminalize drugs, and have a way of regulating their quality, then I think that would help with overdoses. That would help a lot with the death rate we’re seeing that shot up among white Americans and got everyone’s attention a couple of decades ago, but now is evolving into a Black and Brown overdose problem. I think that overall, you’d see less drug deaths because the supply would be safer, it would be regulated.

With regard to treatment, I think that’s a separate and related question. If you legalize and regulate substances without addressing the fact that we don’t have universal health care, we have an extremely race- and class-stratified health care system, any kind of treatment that’s going to be delivered through this system is just going to be stratified.

If you see countries where they’ve had a lot of success with opioid maintenance treatments, France is one I often turn to as an example. My colleagues, who are big buprenorphine advocates, point to France and say, “Look how they lowered their overdose death rates by 80 percent within the first five years of introducing primary care based buprenorphine.”

“If we want French-style results, we have to use French-style techniques. It’s not just buprenorphine, it is also investing in social services.”

They leave a lot of things out of the picture. The fact is, not only does France have universal health care, buprenorphine was not introduced as this private-market, white-exclusive thing, which it still is in the US. From the very beginning it was low-income, largely immigrants who were the anticipated recipients of buprenorphine treatment.

The French also invest twice the amount of money per capita as we do in social services. They bundle up opioid maintenance treatment with social services in community-based addiction treatment centers, where they have peer navigation and housing and employment assistance. It’s just a very different system.

So if we want to get French-style results, we have to use French-style techniques. It’s not just buprenorphine, it is also investing in social services and in people with lived experience working in community-based centers.

That’s why I don’t think that eliminating the drug war, although that would be fantastic, would solve a lot of problems that contribute to racial inequalities, including mass incarceration. We have to address the lack of universal health care and the need for social service investments.

Detail from cover of Whiteout: How Racial Capitalism Changed the Color of Opioids in America via University of California Press. Inset photograph of Helena Hansen courtesy of Dr. Hansen.

The post Whiteout: A Searing Analysis of Racial Capitalism and Opioids appeared first on Filter.

Of the three medications approved for the treatment of opioid use disorder, methadone and buprenorphine are the most commonly prescribed. Both are proven to be effective, and greatly reduce a person’s risk of dying by overdose.

Methadone, however, is tightly restricted; federal law permits it to be prescribed and administered only in specialized addiction treatment settings known as opioid treatment programs, or methadone clinics.

The X-waiver created a number of needless and harmful barriers to access.

Buprenorphine, on the other hand, may be prescribed in any setting. Many formulations can be self-administered. But until recently, health care providers had to obtain a Drug Addiction Treatment Act Waiver—commonly called an X-waiver—to prescribe it.

The X-waiver created a number of needless and harmful barriers to access. These included the eight-to-24 hours of additional training required for prescribers; additional administrative hurdles; and imposed limitations on the number of patients a provider could treat.

Passage of the 2023 Omnibus Bill—which included the Mainstreaming Addiction Treatment (MAT) Act, first introduced in Congress in 2019—has now finally resulted in elimination of the X-waiver. This is critical at a time when overdose deaths have been surging for more than a decade.

In recent years, our nation has lost the annual equivalent of a mid-sized city to drug overdose, culminating with more than 100,000 overdose deaths in 2021. It is important to highlight that the rate of death has not been distributed evenly. Overdose death rates are disproportionately high in communities of color and communities experiencing high poverty rates. These concentrations of overdose deaths are the direct result of decades-long, racist social policies that structurally disadvantage these communities.

The barriers created by the X-waiver requirement served to ration effective treatment for opioid use disorder, thereby reinforcing structural racism and redlining policies in our health and public health systems.

It is now incumbent on the entire health care field to maximize this opportunity to advance health equity.

Buprenorphine has been far more accessible to whiter and wealthier communities, which have benefited from more prescribers willing to obtain an X-waiver. Meanwhile, communities that are predominantly Black, Brown or experiencing poverty have tended to have very limited access to buprenorphine. Methadone, which is subject to requirements like frequent attendance at clinics, has long been the only option—a high-barrier one—for many members of these communities.

The elimination of the X-waiver therefore has the potential to advance health equity across the country. But this will only be achieved if providers and public health agencies actively ensure that buprenorphine is provided equally in financially disadvantaged communities and for people of color.

It is now incumbent on the entire health care field to maximize this opportunity. We must ensure that critical treatments are not hindered by barriers, and that lifesaving care is accessible to everyone in need.

Photograph of Suboxone tablets by Supertheman via Wikimedia Commons/Creative Commons 3.0

The post The End of the X-Waiver Is a Chance to Advance Health Equity appeared first on Filter.