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ESPAÑOLA, N.M. — For years, this town has withstood a torrent of opioid-related deaths, and now claims one of the highest rates of opioid overdoses in the country.

But the battle against opioids in Española is being fought with a paltry force: In a community of roughly 10,000, only three physicians are certified to treat patients with opioid use disorders.

The scarcity of doctors trained to deal with addiction may be particularly acute in Española, but the issue resonates in cities and towns across the country, where roughly 20,000 people die annually from opioid-related overdoses. In the face of one of the country’s most pressing and fastest-growing public health crises, few primary care doctors treat substance abuse disorders, even though they are uniquely positioned to recognize problems and help patients before it’s too late.

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Instead, many primary care doctors follow an old script: Refer patients to addiction centers and Narcotics Anonymous, and move on.

“We’re just watching the ship sink, even though we have the pumps to easily keep the water out,” said Dr. R. Corey Waller, an addiction-treatment specialist who leads the advocacy division of the American Society of Addiction Medicine, or ASAM.

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Michael Botticelli, the director of the White House office of national drug control policy, agreed, describing the absence of a more vigorous response as “deplorable” during a recent forum on the opioid crisis in Albuquerque.

The federal government last year embarked on an effort to double the number of doctors certified to treat addiction with buprenorphine, a drug shown to curb opioid cravings in most patients. That effort has yielded some early success, but according to ASAM, less than 1 percent of primary care doctors are now certified.

Much of the explanation is frustrating.

“I’ve had conversations with a few hundred primary care doctors to try to figure this out,” Waller said. “I get comments like, ‘I don’t want those people in my waiting room.’ Ones who are more well-meaning — which is most — say they have no training to treat this disease.”

There are few incentives to get trained, however, especially in the many states whose Medicaid systems do not reimburse physicians for addiction treatment.

“A lot of people want to malign primary care doctors for not owning their share of the problem, but it’s just not that simple,” Waller said. “We’ve set them up for failure.”

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Until the 2000 passage of the Drug Abuse Treatment Act, the American medical system largely treated those with substance abuse disorders by encouraging abstinence and directing patients to treatment centers, mental health counselors, or 12-step programs like Narcotics Anonymous. Some medical schools — particularly those in urban settings — train students on addiction management, but many only offer cursory guidance on such issues.

Among other measures, the legislation made it possible for more clinicians to treat patients with buprenorphine, one of the few opioid addiction treatments approved by the Food and Drug Administration.

Buprenorphine, most commonly known by the brand name Suboxone, is an opium derivative that produces a normalizing effect on the brains of people who are addicted to opioids. In proper doses, the treatment allows patients to carry out their normal daily activities, while blunting cravings for opioids. It also can block the effects of drugs like heroin and methadone.

But buprenorphine is just one part of addiction management.

The eight-hour certification course currently offered to clinicians seeking to treat opioid use disorders includes four hours of online training and four hours of live instruction. That, experts say, is not enough time to give primary doctors any semblance of confidence that they can manage the psychosocial complexities of patients with opioid use disorders.

Suboxone
Suboxone is used to treat patients with opioid use disorders. Spencer Platt/Getty Images

In addition to writing a prescription for buprenorphine, for instance, doctors must understand how to approach patients who commonly suffer from cognitive impairments and mental health pathologies that often have their roots in early-life trauma. Doctors who coordinate treatment with mental health providers must also navigate at times thorny privacy issues, and brace for the possibility that patients will sell buprenorphine prescriptions on the black market.

To face such complexities after a mere eight hours of training, Waller said, “it can be pretty scary for someone in primary care.”

For these reasons and others, physicians groups have supported the training programs around medication-assisted treatment for opioid use disorders, but only to a point.

The largest physician group, the American Medical Association, backs increased training for the medication-assisted treatment of opioid use disorders among its members, but it opposes mandatory training.

The AMA believes that such training may not be relevant to all primary care physicians. Some doctors do not prescribe opioids, for instance, while medical practices might lose money on such treatments because of inconsistent insurance coverage of opioid addiction medications.

Dr. John Meigs, president of the American Academy of Family Physicians, said opioid abuse “is so rampant, and we’re the specialty with the broad training in comprehensive, whole-person care, that it is appropriate for us to help take care of this need.”

But Meigs himself, who has practiced medicine in rural Alabama for 34 years, said he “has not had time” to become certified, and that he does not know how long the process takes. It is, however, something he intends to do in the future, he said.

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Of all the primary care doctors to have made the transition to treating opioid-addicted patients, Dr. Leslie Hayes is perhaps the most highly recognized.

Earlier this year, Hayes won recognition from the White House as a “champion of change,” for her role in addressing the opioid-overdose crisis.

Her territory: Española, New Mexico.

When she started practicing here roughly 25 years ago, Hayes said she “didn’t realize there was actually stuff you could do, and how much you could do. So I did the best I could.”

That meant she practiced the standard approach to those with addiction disorders.

“The default was to say ‘You need to quit drinking and using drugs,’” she said. “Then refer them to NA. It’s a great option for some, but it doesn’t work for everybody.”

In 2003, Hayes heard about a new program in New Mexico, Project Echo, which trained primary care clinicians remotely in various medical specialties. She worked under the guidance of Dr. Miriam Komoromy, a professor at the University of New Mexico School of Medicine, and by the following year was trained to treat patients with substance abuse disorders and certified to prescribe buprenorphine.

“Leslie is my hero,” said Komaromy. Even though Hayes carries no board certifications in addiction management or OB/GYN medicine, Komaromy said, “she’s one of the state’s recognized experts in opioid addiction in pregnancy.”

Hayes is quick to point out that buprenorphine is not a cure-all. Some of her patients have learned that the hard way.

Bobby Delgado, 45, saw Hayes, who helped him get Suboxone for free because he couldn’t afford the $10 per-pill copay. Within three years, Delgado relapsed.

Dr. Leslie Hays
Hayes at El Centro Family Health in Española, N.M. Steven St. John for STAT

“Suboxone does work, but you have to do your share of the legwork,” he said. “Going to meetings, going to your appointments. All of this is a factor.”

Of all the skills Hayes learned during training, she said the most valuable has been what is known in psychology circles as “motivational interviewing.”

“If you tell someone the reasons they need to stop, they’ll go the opposite way,” she said. “So the idea is to get the patients to voice the reasons they want to quit, so if they voice that, they’re much more likely to follow through with them.”

Hayes said she will ask patients to rate, on a scale of 1 to 10, the importance of quitting drugs, and then rate their confidence in their ability to do so.

“And I always ask what good things they get out of using. If you can figure out what those things are, and if they can figure out another way to achieve that, it can be very helpful.”

Hayes said she sometimes remembers patients she saw before she received advanced training in the treatment of addiction. Among them was a young woman who was repeatedly turned away from busy rehab centers, until she was later convicted on drug charges and ordered by a judge to admit herself to inpatient care.

Years later, Hayes saw her in the local hospital.

“She’d aged so much — her memory was shot, and she was clearly still using and not doing well at all. She didn’t remember who I was, which made me kind of sad,” Hayes said.

If Hayes had been certified to treat the woman with buprenorphine during her early visits, she said, she likes to believe the woman’s outcome would have been different.

“I can’t say for sure, of course,” she said. “But she’d have had a much better shot.”

  • I find it interesting that not once did this article mention the passage of new legislation removing barriers for nurse practitioners to prescribe buprenorphine. Many of our patients would prefer to remain in our practices for treatment and now once we have the required 24CE this will greatly increase access to care. NPs have been providing care for vulnerable populations for the past 50 years and this is just another example of the value added care we bring to health care and health care reform efforts. SAMHSA recognizes that 8 hrs is not enough and they should increase the CE for physicians to equal the requirement for NPs and PAs.

  • I have to agree with Therese Vorel there are NOT enough doctors to treat pai. And the throwing opioids at it doesn’t help in all cases. I my self am taking pain medications fro chronic pain, and have been for 8 years. The medication I am stuck with is the morphine ir and it does help somewhat but marginally so. The other opioids such as OxyContin, ocicodone cause severe reactions, oxymorphone at even small doses causes profound blood pressure drop. To where 1/4 mg caused my pressure to drop to 60 systolic. Luckily I was in the hospital when it was tried. Medication meperidine causes aggression to the point of violence! So morphine is it. Then there’s the trigger point ingestion, then the injections into the nerve bases under fluro ( YEAH who doesn’t like radiation) over the last 5 years I’ve had knee surg 3 times finally having a total knee, then came the total hip opposite side, they are wanting to replace the other hip and knee plus they are suggesting surgery on my shoulder. The lumbar pain they want to do fusions, but having seen what others have had as far as problems post op. Not in my immediate future. The hip was bone on bone when I finally had it done and was told that it was good for about 15 years, so when I hit 75 it will be time for another one! No we need more pain specialist and we need to have Cannabis added to the arsenal of pain medications! The states that have started using cannabis for pain have decreased the numbers of patients on opioids by 30%, and have decreased the number of deaths to opioids overdoses by 25%!!!!! Those are numbers that shows that cannabis can be a viable alternative! But as long as the government is pressured by lobbyist to prevent cannabis from use in medicine we will suffer! The lobbyist involved are the pharmaceutical and alcohol distillers! Neither want to lose their strangle hold on our pocketbooks! Profit over the needs of the patients!

  • Primary care doctors don’t want to be part of the solution because they are part of the problem and are profiting from it.

  • It infuriates me that there’s Not One mention of the fact that there are over 1 Million Americans suffering with Chronic Pain!! The impact this ‘war on drugs’ and Physicians who prescribe opioids is having on the Pain Community is Devastating, causing sudden deaths & suicides from lack of access!!! Yes, it’s tragic that there are So many (mostly trauma survivors) who go undiagnosed, self treat with drugs & suffer in addiction, it’s heartbreaking; but the more Serious problem is that REAL pain patients are stigmatized as addicts & there aren’t enough Dr’s to TREAT PAIN PATIENTS!!! If at least 10% (low estimate) of the population lives in Chronic Pain; out of 10, 000 people discussed in the article there are At Least 1,000 pain patients- HOW Are They getting the Medical treatment THEY Need to Live as Healthfully as possible!!!??? If you’re presenting the Opioid Addiction & the problem with PCP’s; Then Lets talk about the WHOLE PICTURE.

  • Great article Bob. As a PCP in Australia treating opiate addiction for 20 years I believe that just getting people onto suboxone or methadone is 80% of the battle. Following that with a respectful ongoing therapeutic relationship over a number of years allows people to grow and finally come off their substitution medicine. Hey, treating diabetes and heart disease is a lot more difficult than treating opiate addiction. Keep up the good work, Mark D

    • Dr. Mark Davies’s observations are right on the mark! I am an internist and I started treating patients with opioid use disorders (OUD’s) 10 years ago. Hands down, addiction medicine is the most rewarding form of medicine I’ve ever practiced. Assisting a person to regain a sense of control within days of initiating treatment and then progress to rebuilding their lives is incredibly satisfying and rewarding. I’d never considered the relative ease of treating OUD compared treating other well understood disease processes. But it is absolutely true! The vast majority of patients, when they come into treatment are highly motivated to break the cycle of soberity and relapse. They are never surprised or stunned by the diagnosis. They don’t have to persuaded to acknowledge they have problem; they already knew they needed help when they called to schedule an intake appointment. Chances are they’d been contemplating cessation for some time. Getting persons with OUD’s into treatment IS 80% of the battle, but it’s not ALL about reluctance among the effected individuals. Unfortunately, far too many healthcare providers, paraprofessionals, social service professionals, law enforcement officers and members of the general public are unaware effective medication assisted treatments (MAT) for OUD exists. Therefore, they cannot direct persons with OUD to these highly successful treatments. Further compounding situation is a very common misunderstanding regarding the role buprenorphine (or methadone or naltrexone, for that matter) has in recovery. Often, MAT is maligned as a “substitute drug” or “just being addicted to a different drug”. But nothing could be further from reality. Despite partial mu-opiate receptor activity buprenorphine is a drug at low risk for abuse, hence it’s classification as a schedule 3 drug. More succinctly, opioids of abuse are used to get “high” and escape; in contrast buprenorphine is used to diminish or eliminate the desire to use opioids (cravings) and the need to use opiates to feel “normal ” (withdrawal) allowing a patient remedy the circumstance(s) from which they initially sought escape. The physiological dependence which develops with sustained use of opioid drugs is not a new “addiction”. Medically supervised tapering tremendously minimizes relapse risk related to withdrawal symptoms. Finally, if somehow an individual learns of buprenorphine medication assisted treatment the final barrier is the paucity of wavered prescribers in the country which creates a bottleneck limiting access treatment.

  • Peter J. Liepmann’s comment at 4:26pm more concisely explains the issue better than the article above.

    Primary care is getting hammered with progressively diminishing resources to tackle the burden.

  • I think that the PCP’s are already overwhelmed and giving them more responsibility with no increase in resources to handle that is just going to burn them out more. The opioid addicts I see often need help with legal issues, housing, PTSD and other psychiatric conditions, employment, … PCP’s just don’t have the resources to deal with all those other issues.

    • I live in Albuquerque. There isn’t any support for primary care doctors. For one thing it takes months to get an appointment when you are an established patient. Many of us don’t understand why decent doctors stay here.

  • This is all part of the general problem of (not) paying for primary care. In California, Medi-Cal pays $24 for a 99213 (one problem office visit,) less than half the cost of providing it. I wonder why more docs in private practice don’t take Medi-Cal? (Medi-Cal pays a CHC $130-200 for the same visit.) What does Medicaid pay in NM?
    The critical shortage of primary care docs, (and poor payment for visits) means most won’t take (can’t afford) the extra (unpaid) time to do a comprehensive visit for pain problems, so they do the best they can in limited time, and write a prescription for pain meds. That’s half the cause of the opioid problem right there. But blaming docs for the problems in the health care system is self-defeating.
    With the state legislatures blaming docs for prescribing opioids and threatening licenses, a common response of primary care docs is simply to stop writing for ANY strong pain medications. If you’re a patient with severe pain, you’re out of luck.

    This is just one more effect of not paying for primary care, and the resulting shortage.

    • I don’t know what medicaid pays for primary care in NM, but physicians here have the lowest reimbursement for everything. There are 2 or 3 other states in the same pickle, and they aren’t even around here. Texas, AZ, and CO doctors are paid wonderrously. We have some really great physicians, whose families live here, or they love the relaxed multicultural life style.

      Needless to say–this is hard-extra stress on physicians. There’s an old saying about horses, and why horses die quickly—Rode hard and put up wet. —That is especially true here with our physicians.

  • Great article and an important topic. However as the spouse of a family practicioner I take some issue with the idea that the answer is always to train the PCP’s more and then hold them accountable. Agreed that PCP’s must be better trained on how to avoid overuse of opiates for pain so they do not continue to contribute to the addiction crisis by creating new addicts. However, once a patient is addicted (and not always due to poor prescribing behaviors), I question whether PCP’s are the answer for treating that disease. I have watched my wife’s workload increase, paperwork increase and effective pay decrease as payers reduce reimbursement levels. Yet we continue to expect this group of tapped out people to take on all of society’s most complex health related issues such as depression, obesity, diabetes and now opioid addiction…. All in a series of 15-20 minute office visits. We have no problem referring someone with joint pain to an orthopedic surgeon so the patient can be convinced that they need some expensive imaging or procedure of questionable benefit but consider a PCP referring and addict to an addiction center as an “old script”? Perhaps we should be creating better services and improving the addiction centers’ effectiveness rather than trying to place yet another complex societal issue at the feet of an overworked, underappreciated group of physicians while specialists rake in the cash.

  • I am an FNP. Nurse practitioners are not allowed to prescribe Suboxone. Thus, my patients never get it. I wanted to take the training for my own knowledge. I was not allowed to. Many NPs work with a large number of addicts and do not have access to MDs who can prescribe Suboxone. What a shame

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