High-dose drug treats fentanyl overdose

When someone overdoses on fentanyl and makes it to the hospital Emergency Department, a high dose of buprenorphine is a lifesaver.

Dr. Gail D’Onofrio, an expert in emergency medicine and addiction, knows that to be true. “In emergency medicine, I was the first person to prescribe in the Emergency Department in the country,” she said. “In the Yale health system, I had the expectation that every faculty member who served here in New Haven had to be waivered.”

The waiver, known as a data waiver or X waiver, requires eight hours of training and allows doctors, physician assistants and nurse practitioners to prescribe buprenorphine. The rules were relaxed because of the pandemic, but it’s still a barrier for many people addicted to fentanyl to getting their medication, doctors say.

Drugs like buprenorphine are known as partial agonists because they bind to the same receptors as full agonists like fentanyl or heroin, blocking the dangerous drugs but having weaker effects.

“We know that opiate agonists are the most important treatments for people with OUD,” or opioid use disorder, D’Onofrio said. “They retain people in treatment.” A study last year showed that high-dose buprenorphine was safe for people addicted to fentanyl.

Yet not all hospitals give the medication and not all their doctors are certified to dispense it. For some, eight hours of training are required to receive the X waiver, although that requirement was waived in April 2021 for doctors who see 30 or fewer patients with opioid use disorder.

“You do need to go through several hoops” to dispense and prescribe buprenorphine, D’Onofrio said. Not all doctors even want to prescribe buprenorphine, she said. It may be they don’t want to go through the training or they don’t want the stigma of addicted patients in their waiting rooms, she said.

Dr. Craig Allen, medical director for the Rushford Center behavioral health network, part of Hartford HealthCare, said, “eight hours of training can be a barrier for a health care provider who isn’t planning to make a career out of treating people with addictions.”

“It’s ironic because the medical provider didn’t have to have any extra training in order to write a prescription for OxyContin,” Vicodin or Percocet, which started the opioid crisis, Allen said. “But now there’s a medication that’s safer” and yet its use has been regulated by the federal Substance Abuse and Mental Health Services Administration.

Yet it’s critical that people who have overdosed be given the drug, or Suboxone, which is buprenorphine plus naloxone, D’Onofrio said. “The mortality rate for someone who has overdosed is 5 percent” within a year, she said. Few other issues have a mortality rate approaching that, she said.

“There are 106,000 people that die of overdoses every year and 70,000 die of fentanyl” or other opioids, according to the Centers for Disease Control and Prevention, she said.

“The sooner you start someone onto a medication for opioid use disorder, the better off they are,” Allen said.

He said 75 percent of patients started on a buprenorphine or other medications in the Emergency Department were still in treatment one month later.

While hospitals can dispense buprenorphine, and all doctors at Yale New Haven Hospital, including the Shoreline Medical Center, are certified to dispense and prescribe it, a patient then must then go to a doctor in the community to get a refill prescription. D’Onofrio said a few doctors at Bridgeport and Lawrence and Memorial hospitals also have the required waiver, but not at Greenwich or Westerly in Rhode Island.

Allen said all of the behavioral health doctors at Rushford, which has seven locations, and Natchaug and Backus hospitals have X waivers. “The number in our other facilities is growing,” he said.

“You don’t have to be data-waivered to start someone on the medication,” Allen said. “If you are X-waivered, then you can give them a prescription when they leave.”

D’Onofrio is promoting the use of high-dose buprenorphine in the Emergency Department because its effects will last for several days, until the patient can get to a doctor who is allowed to prescribe the medication. If patients are given low-dose buprenorphine, which is taken under the tongue, there still may be “disruptions in people’s thought processes and their ability to make decisions.”

Using high-dose buprenorphine, more than 12 mg per day, “you could get to a better level quickly and it would be sustained and the duration would be at least three days,” D’Onofrio said. The hospital can give “a warm handoff with a place in the community, based on their insurance status.”

Cornell Scott Hill Health Center, Fair Haven Community

Health Care and the APT Foundation all are places that will accept patients without health insurance.

Not all hospitals dispense buprenorphine, either. “The uptake through all EDs is not as good as we want, particularly … rural and community hospitals,” D’Onofrio said. “You’re even limited in terms of what pharmacies you can go to.”

“We need to X the X waiver and eliminate one more barrier to treatment,” she said.

Rushford has a program, Meriden Opioid Referral for Recovery, which supplies first responders with Narcan and then gives patients a case manager to help them find the best routes to recovery.

“Our team goes out there and meets with them on the street,” Allen said. “If you’re living out on the street, if you don’t have the wherewithal to get to a clinic, you’re not going to have the access” to medication.

In New Haven, “we’re very lucky. … We have a lot of options for people,” D’Onofrio said. Still, she said, “most of them need a champion to say, ‘you’re doing the right thing.’”

Buprenorphine works by binding to the same receptors in the brain as fentanyl and other full agonists (known as mu receptors). Because “those receptors would be already occupied, you would not die,” D’Onofrio said.

Allen said a patient must have started going into withdrawal before being given buprenorphine. “Fentanyl stays in your system for a long time,” he said. Since buprenorphine binds to the same receptors, “if you give it too soon, before heroin or fentanyl is off the receptor, it can knock those opioids off too quickly and [the patient] can go into withdrawal,” he said.

Symptoms include upset stomach, shakes, sweating, “the worst flu you’ve ever had,” Allen said.

Buprenorphine has only been given to patients who have taken fentanyl, she said. It hasn’t been tested “in a prospective way.”

Another treatment for opioid addiction is methadone. “There’s a movement of trying to have regular pharmacies dispense methadone,” D’Onofrio said, but it has to be given every day and it’s a more dangerous drug than buprenorphine because it’s a full agonist.

Yale New Haven is giving patients a seven-day injectable dose of buprenorphine on an investigational drug protocol, D’Onofrio said. “That is not available to the world yet,” she said.

The 30-day does is called Sublocade. “That is available, but it’s not an option that most EDs are using,” partly because it is expensive.