Why Aren't More Doctors Helping People Addicted to Opioids?

Philadelphia's innovative treatment program for incarcerated opioid users is failing. Is it because doctors don't want to treat opioid addicts?


Discarded needles are not an uncommon sight in parts of Philadelphia, which has the highest overdose death rate of any large city in America. CHARLES MOSTOLLER/Charles Mostoller/Newscom

Philadelphia's innovative program to provide medication-assisted therapy (MAT) to prisoners with opioid use disorder has hit a snag, and an official at the Philadelphia Department of Prisons says federal limits on how many patients any one doctor can help are partially to blame.

Under federal law, doctors can concurrently treat only a limited number of patients using the drug buprenorphine, a partial opioid agonist that scratches the itch (so to speak) brought on by opioid cravings. The drug's effects are much milder than those of prescription painkillers and heroin, which allows patients to manage their addiction or dependence without being incapacitated.

The Philadelphia County Jail is currently struggling to provide buprenorphine to all the patients who need it because physician John Lepley, who has a federal waiver that allows him to treat 250 patients concurrently, recently left the facility for another job. None of the jail's remaining buprenorphine providers can prescribe as much as Lepley. According to Nina Feldman at WHYY,

The prison employs nine doctors with 30-patient limits, and one with 100. But because of the way the doctors' schedules are organized and how they are distributed throughout the facility, [Chief of Medical Operations Bruce Herdman] said he doesn't have enough doctors to meet the demand of his patients.

To treat just 30 concurrent patients, qualified providers must complete eight hours of training and receive an additional Drug Enforcement Agency (DEA) prescribing number. Even after completing that training, providers must wait a full year to apply for federal permission to treat 100 patients concurrently. According to Herdman, most of his team won't be eligible to treat 100 patients concurrently until June 2020.

In recent years, harm reduction advocates have suggested that the training requirement and patient caps endanger patients by discouraging provider participation. Herdman agrees, telling Feldman, "That limitation on prescribing is really weird. A regular physician can prescribe all sorts of other narcotics without additional training. But for buprenorphine, they want additional training."

I am skeptical that the time commitment alone can explain the massive gap between the number of providers who could get the waiver and the much smaller number of those who do. Eight hours worth of webinars and modules certainly do not explain why some number of waivered physicians—more than 50 percent, according to one survey—do not treat the maximum number of patients allowable by law.

In 2018, researchers pointed to a host of reasons why doctors do not obtain, or make maximum use of, the buprenorphine waiver: a small number of doctors don't think medication-assisted therapy is effective, while others don't find treating heroin addicts to be lucrative enough (doctors who do make it lucrative run the risk of going to prison). But the biggest issue is that the relative paucity of waivered doctors means every doctor with a waiver is being asked to serve far too many patients.

Among waivered doctors who are not treating as many buprenorphine patients as the law allows, 36 percent told researchers they lacked capacity; 10 percent were worried about diversion (and likely the DEA's response to said diversion); and 8.8 percent did not want to be inundated with buprenorphine requests. The DEA and the Substance Abuse and Mental Health Services Administration do not control reimbursement rates for MAT treatment, but they do jointly oversee the waiver program and are responsible for the distorted incentives that have created a massive gap between need and capacity.

We must also consider the fact that applying for permission to prescribe buprenorphine puts physicians under intense DEA scrutiny, and that the DEA is known to raid the homes and offices of doctors who prescribe the drug, sometimes for reasons that don't hold up in court. While there are doctors who do hand out Suboxone in a way one might charitably describe as uncareful, the drug is significantly safer than methadone, which is itself significantly safer than illicit fentanyl and heroin. Put another way: if it were as easy for Philadelphians to obtain pharmaceutical buprenorphine as it is for them to obtain illicit fentanyl, there would likely be fewer Philadelphians in the county jail and fewer still in the ground.

If you haven't already, please read Jacob Sullum's recent Reason feature on the deadly consequences of the feds micromanaging prescribers, and my interview with Christopher Moraff on Philadelphia's fentanyl problem.

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  1. Because they’re evil and deserve what’s coming to them.


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    2. Nah, not evil, but definitely deserve the consequences of their own actions.

  2. A total of 2 people should be involved in buprenorphine treatment (or any other, for that matter:

    1. Patient
    2. Doctor.

  3. Is it because doctors don’t want to treat opioid addicts?

    No, its because doctors don’t want to go to jail for treating opioid addicts.

    1. ^^^this

  4. “Why Aren’t More Doctors Helping People Addicted to Opioids?”

    Who got them addicted to opioids in the first place?

    1. The ones in the prison system? Street dealers.

      1. Most doctors have offices accessible from the street, true enough.

  5. Merck doesn’t want them to?

  6. Who got them addicted to opioids in the first place?

    *looks around,checks site url*

    The person using opioids, taking them regularly and with increasing frequency and dosage.

    1. The other name for that is “addictive personally”
      Every drunk, druggy or junky started on mother milk.

  7. These are the least favorite patients of any doctor I know or have known [quite a few].

  8. opioid use disorder

    Oh come on.

    1. F11.2

  9. My doc is keeping me on them as we both agree it’s the best thing for me.

  10. “I didn’t dream of being a doctor, work my a** off to get good grades in HS and college, get into and through medical school and endure residency training, only to end up supplying drugs to addicts for the state.”, said pretty much every doctor I’ve ever met. As far as reimbursement, look up average medical school + undergraduate student loan debt in recent years. Hey, let’s force doctors to do it! Because, it’s for the greater good of all.

    1. Where is force mentioned in the article? What’s discussed is the asinine regulatory process preventing doctors from treating more than a certain number of people.

    2. It might have been informative for Riggs to try to run down the doc with the 250 patient limit, and see why he left the prison system.

      I’m going to go out on a limb and guess he left because, with the ability to treat that many patients, he can make a lot more money working in the private sector.

      Which would make this more about rent seeking than drug restrictions.

      Though, both are government created problems. It’s just that there are fewer heroes when you look at the whole truth.

  11. How about you just legalize all opioids for OTC and let people do whatever they want? Any problems would be self-correcting.

    1. You will need to first ban Narcam. My neighbor is an EMT in a average working class town (50,000). He has gone to the same address, same junkie four times in one day to administer Narcam…. I would have administered saline after the second time. Problem solved.

      1. Thank goodness you are not an EMT.

      2. You just described murder. Good that you admitted that.

        You are too gutless for medical. Go somewhere else.

    2. ” Any problems would be self-correcting.”

      Sure, Let’s stop prosecuting DUI, too… same rationale. It’s not like they can possibly harm anyone else on their way down, is it?

      1. They harm fewer people than the narcotics cops do.

  12. Face it, folks. The DEA is a terrorist organization whose unstated but obvious goal is to kill as many Americans as possible.

    It’s time to disband the agency, even if we don’t send it’s many criminals to jail. At least force them into other criminal enterprises.

    1. C I A black budget funding? Anyone? Bueller? Anyone?… ask any ‘Nam Vet. ask any Afghanistan Vet. Hell, read the “Pat Tillman” story if you want a first-hand account of what’s really going down.

  13. Mike Riggs solution to opioid crisis: just let Mike Riggs do all the opioids and then no one will die to them.

  14. Because buprenorphine can be abused by sufficiently motivated prisoners. Institutions don’t like too much of that stuff running around inside the walls.

    There are newer drugs but they (surprisingly!) are more expensive.

  15. The states made a mistake.

    They kept adding barriers to docs getting on board.

    It should be a primary care model, not subspecialty.

    The result is another missed opportunity to decriminalize and move to a medical based approach.

  16. Truth is a lot of doctors are terrified. I’m a chronic pain sufferer and it can be like pulling teeth to get them to prescribe pain meds to even people like me who really need them.

    If they are scared to prescribe them to those who need them it doesn’t shock me some are reluctant to help addicts.

    1. I shouldn’t be surprised when I find how many people are in that camp. Myself included.

    2. Blame the medical profession itself. They wanted this ‘responsibility’ all to themselves. Back when the government was debated the Controlled Substance Act the profession should have stood up and said “you all are nuts, and we are not going to play along.”

      They didn’t.

      Instead they looked at it and thought “give us total control?” Because ‘we’ are the ‘only’ ones capable of managing these drugs? “Yeah, sure that’s the ticket!”

      They agreed to make this Frankenstein, now they have to deal with it, and I don’t give a damn.

    3. “If they are scared to prescribe them to those who need them it doesn’t shock me some are reluctant to help addicts.”

      This is a pendulum that swings back and forth. For a while they’re afraid to prescribe opiates, for fear of making addicts, but stories of real suffering emerge and then they go the other way, for fear of leaving anyone suffer, and they make more addicts, but complaints about rising numbers of addicts causes doctors to scale back prescriptions, and it just goes back and forth, back and forth.

  17. Between the innocent sufferer who truly endures unmanageable pain but has never done any crime and who does little or nothing to aggravate their condition, and the lazy, lying, stealing, filthy, totally unreliable drug fiend lie:

    (A) the hungry lawyer on the prowl, looking first, foremost, and always for the deepest pocket and some angry accusation that will get their fingers into it.

    (B) the weasel politician, who can’t figure out that there are not magic answers to the problems that extremely dysfunctional people may have, nor can society spend an infinite amount of money in pursuit of such. In the end we have to use brute force and physical walls to quarantine bad behavior and protect the rest of us. People incarcerated will not get infinitely ideal care all of the time. That is not realistic thinking.

    (C) People who very zealously demand that all Americans never offend, demean, inconvenience, or even arrest, try, and imprison each other for unacceptable behavior will never agree to the imposed social discipline it takes to roll back drug invasions (mistakenly labeled epidemics.)

    1. Amen brother. Someone who gets it.

    2. ” the weasel politician, who can’t figure out that there are not magic answers to the problems that extremely dysfunctional people may have,”

      Ok, that’s just flat out wrong. Which is a real shame, because otherwise you were hitting it out of the park.

      Those politicians really can figure things out. What they have figured out is that there are plenty of extremely dysfunctional people who are quite susceptible to believing claims that there are magic answers to all the worlds problems, and those extremely dysfunctional people vote.

  18. Unless doctors can stop illegal aliens from crossing the border with Fentanyl, what else can they do?
    There are those of us suffering from cancer and/or chronic pain, do we just get kicked to the curb?
    Having known way too many people who have ruined their lives from substance abuse, I’ve learned that hard lesson; you can offer a hand of help, but only they can change their lives.

    People who live to get high, will always find a way. Honestly, Can you stop that?

  19. Perhaps some of the doctors are also addicted and they’re all just big enablers?

  20. Can you imagine how strong we would be as a species by now if we quit propping up the weak?
    Darwin’s Theory of Evolution was hailed a breakthrough in 1859. Fast forward to 2018 and we have done everything possible to Fuck it up.

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  22. WHERE in our Constitution is it enumerated to the Federal Government to have anything to do with what we do/do not put into our bodies? Nowhere, that’s where. So HOW is it FedGov even mandates these permissioin slips for trained medical professionals to administer that or this substance?

    If FedGov were overnight barred from meddling at all with what we do/do not put into our bodies the drug problem would go away almost entirely. It is largely driven by the black market criminally connecte distribution system. THIS is how so many get hooked on junk… the profit motive is so high it always pays to find/make new customers.

    1. The medical profession need to address this issue from inside, too. FAR TOO MANY doctors freely administer these things, They are bowing down to the “felt need” they perceive that people need relief from pain. Pain ain’t fun, I know firsthand, as I’m in a lot of it from an old injury. There are non-pharaceutical ways of dealing and coping with it which are not taught. I recently had major surgery and, without fully informing me, the anaesthesiologist included fentanly in the knockout cocktail. He said it was to “help with pain”. He also gave me a scrip for more at home, that stuff was SO horrible, I felt like I was extremely drunk, disoriented, freaking out…. coming out of the anaesthesia was a frightening long road…. I’ve been “out” for six prior major operatioins, and every time I’ve gone from totally out to fully awake in a few seconds, felt great, wide awake, aware, clear-headed like I’d just had a nap. Not this time. If there is a next time (please, no!!!) I will ask the pointed questions no patient is ever bold enough to ask…. and never allow that junk again.

      1. My question is WHY did he even put that stuff in the drip? Never needed it before… over the top overreasponse to a possible situation. Don;t anyone ever try and tell me such drugs are not overprescribed. I did not need it, no reason for it, and it was a horrible experience. I also saw it on the bill…. $350 for some vanishingly tiny amount, a few mG… other than his time, thelargest charge on the bill. THAT”s why. It is apparently a very high profit item. So money is driving the epidemic of opiod addiction. Time this gravy train gets derailed.

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