Like all aspects of healthcare, addiction-based healthcare is part of a larger system of patients, physicians, and lawmakers. Problems with treatment can come from individual patients and physicians, but they can also be systemic problems — widespread effects that are consequences of the way our healthcare and regulatory systems are set up. The main systemic concerns we are seeing in addiction right now have to do with regulation. Should medications like buprenorphine be restricted, and if so, how much? Should addictive painkillers be restricted so fewer people get addicted in the first place? How and how much? Who should be punished for violations, the doctors or the patients? Or both? And how can we enforce these rules?
Attempts to answer these questions have led to what seems to me like an endless loop of adjustment and readjustment. If people seem over-medicated, and the amount physicians can prescribe is curtailed, then physicians will back away from prescribing those types of drugs that draw regulatory attention. Suddenly the supply of medications is cut off, and people who are sick or in pain feel they are under-medicated and put more pressure on the ERs, regulations are relaxed, and we return to the problems of drug diversion and addiction. And then it starts all over again.
This repetitive cycle of problems is nothing new — we see it in economics, in the seesaw of supply and demand. We also see it in biology as the concept of ‘homeostasis’. Homeostasis is the idea that the human body needs to be in a certain precise and delicate state — a specific temperature, a specific acidity, a specific level of water, etc. — and that whenever that balance is thrown off, the body rushes to correct it. When the corrections go too far in the other direction, countermeasures are activated against that change to bring it back down towards the starting point — and so on. The result is an ever-changing system eternally seeking the perfect balance point.
What works for the human body resembles what we need to achieve in the field of addiction medicine. In this case, the ‘balance point’ is a state in which each patient’s perfect amount of medication is decided between that individual patient and a compassionate, well-trained, well-informed physician. In order to reach and maintain that state, the system requires a certain amount of flexibility; we need measures in place to deal with physicians who overprescribe out of selfishness or carelessness, but we also cannot restrict other physicians from performing at their highest capability. The current 100-patient limit for buprenorphine certainly prevents a certain amount of overprescription and black-market pill sales, but it also prevents physicians like me from providing services to all the patients who require them.
One of the mistakes people have when thinking about this ‘endless loop’ of over- and under-regulation is in thinking that one blanket solution will ever be enough to enable everyone to administer the correct amount of medication to all patients in all cases. If that solution exists, we’ll never find it — there is no one answer. We may have to choose on the side of overprescription — focusing more on preventing pain, even though free use of painkillers may lead to addiction — or we may have to choose underprescription, where we withhold our strongest painkillers in some cases, so that people are in pain but are not at risk for developing a lifelong dependence. Such decisions should only be made between a patient and their physician, and in order to make them effectively each physician and patient need access to the full range of options along the spectrum of painkiller prescription. Regulation is a useful tool in combating the addiction that comes from physician carelessness, but it is not a catch-all solution for the complex problems that arise during the treatment of a chronic condition like addiction. Right now, the best thing we can do is continue to educate lawmakers and physicians so that they can design a system for the maximum flexibility and utility that has the most power to help the most patients.