In the practice of addiction medicine, we are often faced with barriers that don’t make sense.

I’m an addiction medicine physician and I have been practicing in Maine since August of 2020. I must say there have been some absolutely maddening experiences since my arrival. Most of my frustrations have been centered on MaineCare and its blanket policy on daily buprenorphine limits.

The drug scene in Maine has changed significantly since buprenorphine was first introduced and approved by the FDA for the treatment of opioid use disorder in 2002. At that time, heroin and opioid pain medications such as oxycodone and hydrocodone were the predominant drugs.

These days, fentanyl has taken over the drug supply. Fentanyl is a synthetic opioid that is about 50-100 times more potent than heroin, and its presence has been cited as the main cause of the continued rise in opioid overdose deaths in this country. I can count on one hand the number of times I have seen heroin, oxycodone or hydrocodone on a drug screen in the last nine months — but fentanyl is a daily occurrence.

The introduction of fentanyl into the drug supply and its prevalence in our community has changed how we should react to, and treat, this drug epidemic. Unfortunately, MaineCare and its policies haven’t adapted. MaineCare will only cover up to 16mg of buprenorphine per day without requiring a prior authorization. In my experience, depending upon when this paperwork is submitted, it can take 24 to 48 hours to be approved. However, if you are really unlucky and happen to be open and taking care of patients on a Friday afternoon, you’ll have to wait until at least Monday.

So who cares about a daily limit of 16 mg of buprenorphine? With the increased potency of fentanyl, I commonly see patients requiring higher doses of buprenorphine to alleviate cravings and withdrawal symptoms. There are times when my patients are displaying withdrawal symptoms in my office despite being on the 16 mg dose and fighting the craving for heroin or fentanyl. Unfortunately, I have to say: “Although the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Food and Drug Administration (FDA) guidelines support the prescription of up to 24 mg of buprenorphine per day, I have to submit paperwork and get MaineCare’s approval before I am allowed to increase your dose so I can adequately treat your symptoms. Hopefully I will have an answer within 24-48 hours. In the meantime, can you please not use any drugs?”

If only buprenorphine was as easy to prescribe as OxyContin.

We need to wake up. One of two things happens to my patients when they have to go without an adequate dose of buprenorphine: 1) They resort to opioids in attempt to alleviate their withdrawal and cravings or 2) they buy buprenorphine on the street. Buprenorphine diversion is the most common reason that I have come across, both anecdotally and in writing, for placing limits on buprenorphine doses. If we truly want to discourage diversion, let’s treat these patients adequately and in line with the current, evidence-based guidelines so that their symptoms are controlled and they go to the pharmacy instead of the street.

There is plenty of data that shows that increased access to buprenorphine decreases opioid overdose death. There is no data that I am aware of showing improvement in outcomes by limiting daily medication doses below the accepted guidelines.

As a physician, I am expected to practice medicine based on evidence and my license is dependent upon that. It is my strong belief that our public health policies should be held to the same standard.

More Mainers continue to die each year from opioid overdose, so let’s allow licensed providers to assess and treat their patients using evidence based practice and within the current guidelines. It’s not too much to ask considering this is what we are expected to do in every other field of medicine.

We should be able to do this without asking for special permission, tripping over red tape, and filling out paperwork that delays treatment. “What we’ve always done” isn’t working and is unacceptable.

Nick Gallagher, D.O., is an emergency medicine physician and addiction medicine specialist in central Maine. 

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