Viola Lee

Last Friday, final-year medical students at Yale School of Medicine participated in a mandatory four-hour training course for prescribing buprenorphine — a drug that helps people stay in recovery by alleviating withdrawal symptoms for patients suffering from opioid use disorder.

This mandatory buprenorphine training is part of a new program that the School of Medicine is implementing this year for graduating medical students during their capstone course. According to the Substance Abuse and Mental Health Services Administration, physicians are required to participate in a training course in order to obtain a waiver to prescribe and dispense buprenorphine — colloquially referred to as the “X-License” among medical professionals. Yale is one of the first medical school programs in the country to provide this training to fourth-year medical students, according to David Rosenthal, professor of general internal medicine and course director of the school’s capstone course that offers buprenorphine training.

“We are providing medical students with the official training to receive this waiver to prescribe buprenorphine, which will prepare medical students to combat the opioid crisis. It is important to train as many doctors as possible to be equipped with the right tools,” said Caroline Falker, an addiction medicine fellow at the School of Medicine, who co-led the training course with Kenneth Morford, a postdoctoral associate at the School of Medicine.

Morford similarly stressed the importance of having all students obtain the X-License, noting that there are currently not enough health care providers capable of prescribing treatments for addiction.

In addition to this effort, a team of students and faculty at the School of Medicine developed a mobile application called BUP Home Induction, which explains how to administer buprenorphine for the first three days — the “induction” phase — of the regimen. The app was introduced during the buprenorphine training.

According to Morford and Falker, many people suffering from opioid addiction have already tried buprenorphine without a formal prescription. However, patients who take buprenorphine without a formal prescription are limited to online patient education materials, which are often inadequate. Providing guidance to patients, one of the key goals of the BUP Home Induction app, may therefore improve adherence and prognosis.

A team comprising Rosenthal, psychiatry professor Theddeus Iheanacho and medical students Josh Feler MED ’20 and Patrick Liu MED ’21 developed the app over the past year with the help of $25,000 from a Veterans Affairs innovation grant to develop this application.When he started this project, Rosenthal said that he was committed to providing more effective instructions for patients on how to start taking buprenorphine at home, instead of having it administered at a hospital, clinic or detox facility.

“Doctors used to hand the patient a piece of paper with instructions on how to take buprenorphine. The paper would get lost, and the instructions were presented in a dull, long and complicated way. It got me thinking: There has to be a better way to do this, and the idea of building a mobile app came about,” Rosenthal said. “Pew Research last year reported that 90 percent of Americans between 18 and 55 years of age have smartphones, so this app could be a good way for people to find instructions for their treatment. Technology is a great way of amplifying solutions.”

Upon completion of the first phase of the app, which is free and accessible to anyone with a smartphone, the team has been testing it among patients, many of whom are veterans, at the Connecticut VA where Rosenthal directs the Homeless Patient Aligned Care Team.

The first phase of the project outlines the induction phase of drug administration, providing detailed information about dosage and timing of administering buprenorphine. The final version of the app will offer directions for the entire buprenorphine regimen.

Rosenthal noted that the app could lead to better communication and better results. The app’s convenient and simple user interface caters to this objective of making the induction phase of buprenorphine more accessible for patients. In addition to helping patients understand their treatment regimen, the app is intended to empower doctors and prescribers with a convenient educational tool to provide to their patients, he added.

“There is a strong social stigma around treating people with opioid use disorders, which is a serious problem,” Rosenthal said. “The fact that a special waiver is required to prescribe such an important medication like buprenorphine is part of this stigma. Ideally, we should remove the X-License requirement. We need to train and empower the entire medical workforce to help tackle this crisis.”

Until legislation reflects these concerns, he and like-minded colleagues believe in training as many people as possible to receive the X-License. Although other withdrawal relief medications exist, buprenorphine is generally considered safer than alternatives such as methadone, according to Rosenthal.

Last Wednesday, the National Academies of Sciences, Engineering, and Medicine published a report that argued that medications to treat opioid addiction are effective and save lives but that barriers like the X-License requirement prevent broad access and use. The report emphasized that stigma and inadequate education, as well as current regulations around methadone and buprenorphine including waiver policies, patient limits and restrictions on treatment settings, are limiting physicians from providing care to patients in need.

In addition, a 2015 Yale study found that outcomes for patients treated with buprenorphine immediately upon their admission to the emergency room were drastically improved compared to patients who did not receive buprenorphine in the ER and instead were referred to an addiction clinic after they were discharged.

This finding illuminated the importance of buprenorphine accessibility in early stages of treatment. As a result, Yale’s emergency medicine residency program trains all residents to prescribe buprenorphine.

The Drug Addiction Treatment Act, which mandates a waiver for prescribing buprenorphine, went into effect in 2000.

Viola Lee | kyounga.lee@yale.edu

Clarification, March 29: A previous version of this story stated that fourth-year medical school students participated in the mandatory buprenorphine training. The story has been updated to clarify that students in their final year of medical school participated in the training, since some medical school students are enrolled in the School of Medicine’s 8-year M.D./Ph.D. program.