Many primary care practitioners have been avoiding the battle against opioid addiction and opioid overdoses. But they shouldn’t.
Embedded in their communities, primary care doctors and nurses are perfectly positioned to treat addiction and champion care for those struggling with the use of opioid pills or heroin. Our expertise is in getting to know our patients and providing longitudinal care for those with chronic conditions like heart disease and diabetes — and addiction.
The impact of the opioid epidemic is staggering. In just the time it takes to read this article, another American has likely died from an opioid-related overdose. I witness the effects of this tragedy every day among my patients and their families in my primary care clinic in the Charlestown neighborhood of Boston.
Someone needs to take charge. I believe that community-based primary care practitioners should take the lead.
Michael Botticelli, director of the White House Office of National Drug Control Policy, agrees. At a recent forum in New England, he called the opioid epidemic “a national crisis that manifests itself as a local problem.” Arguing that local problems require local solutions, Botticelli called for further integrating addiction treatment into primary care.
My primary care colleagues and I provide longitudinal, community-based care for chronic diseases that require frequent and long-term attention. Addiction is clearly one of these. Continuity of care lets us identify and address the underlying causes of addiction and help patients build supportive networks, secure stable housing, and avoid familiar triggers of relapse.
At the same time, we can help them manage their diabetes or quit smoking. Paying attention to an individual’s whole health, including opioid addiction, makes medical sense and is financially smart. In fact, research highlighted by the federal Substance Abuse and Mental Health Administration shows that caring for “substance use and physical health together improves both physical health and substance use conditions.” In other words, treating addiction is good for diabetes and vice versa.
But primary care providers need support to ensure access to care for patients with addiction and to properly care for them. Barriers to care include low payments from insurance companies, little training in addiction care in medical schools, and unnecessary red tape for using buprenorphine, a medication that reduces cravings for opioids. Because of these barriers, relatively few doctors treat patients with opioid addictions. The short supply of clinicians taking on this task means that fewer than half of patients with addiction who need care can get it in most states across the country. This shortage leaves many patients out on the streets without treatment or waiting months for lifesaving care. Many die as a result.
It’s akin to a primary care provider not treating a patient with diabetes because the doctor isn’t familiar with insulin or can’t prescribe a lifesaving heart medication.
Leaders across the country have called attention to this access problem. But we need to match these calls with action, beginning with support for primary care providers at the front line of the opioid epidemic. And we should all get behind what has been shown to work in addiction care.
There are, to be sure, success stories in addiction care. Many of these start with interdisciplinary care teams that bring primary care doctors and nurses together with social workers, mental health counselors, and health coaches to follow patients along their path to recovery. At my clinic in Charlestown, recovering addicts are integral members of the care team, often acting as health coaches. They have the on-the-ground knowledge needed to help patients navigate the complex maze of addiction treatment. This shared responsibility model has been the norm for years in the management of diabetes, heart disease, and other chronic conditions. It should become the standard of care for addiction treatment, too.
When a particularly challenging patient comes my way, there are specialists to help. Several programs, such as Project ECHO out of the University of New Mexico School of Medicine, help connect community providers to the specialty support they need to care for certain patients.
Addiction care training is finally making its way into medical schools and residency programs. While special training for medication-assisted treatment such as buprenorphine is still not required in the vast majority of medical schools and residencies across the country, it is increasingly being made available to trainees at places like Massachusetts General Hospital and the University of Washington’s rural family medicine program. These are important first steps in making addiction treatment as accessible, destigmatized, and standard as is the care for ear infections, migraine headaches, and heart disease.
Supporting front-line primary care providers and their teams will go a long way toward improving both access to care and the quality of care for patients with opioid addictions.
By opening their doors to patients struggling with addiction, primary care practitioners can provide the best care possible for these patients, treating their diabetes along with their addiction. This kind of care will help keep those struggling with addiction off the streets, improve their whole health, and hopefully prevent another tragic overdose death in a public bathroom or teenage bedroom somewhere in this country.
Julian A. Mitton, MD, is a senior resident in global medicine and primary care at Massachusetts General Hospital in Boston.
The patient also must want help. If we prescribe less opiates, trying to wean the patient, it is forcing the out onto the street to make up the difference. We cannot force them to sign up for, or sign into, an addiction program. I applaud the discussion, and all the caring efforts by providers and the community. I would welcome any and all suggestions for most effective methods of reaching the patients in need. What have you heard about the use of the 6 month slow release buprenorphine implant?
This is one of those ideas that sounds good on paper.
I was a PCP for 17 years through 2005. And I went through treatment for narcotic addiction beginning 12/90 (still clean, sober). I left primary care because of the increasing non-clinical demands. What I gather is they are much worse now. As a PCP I recognized I had many illnesses I was comfortable treating and plenty I was not. And juggling several chronic diseases in a given patient is time consuming. Past residency and outside centers with grant money, devoting adequate time to more than one acute issue is a no-go, particularly if one is an employee, though also as a practice owner/partner. (An ongoing source of frustration to doctors and patients alike.)
It’s good there are recovering people in your clinic. On the whole, doctors understand addiction poorly. With the reprehensible and self-defeating behaviors (of us) and the high relapse rates, most docs are not motivated to devote much time to addiction. And patients that need help most are often resistant, especially if they have been getting prescriptions. The opposite crisis does give PCP’s unique opportunities but they need more education about addiction per se, not just overprescribing as is required in my state.
I have written numerous letters to editors and politicians pointing out the irony that family physicians and hospital ERs will prescribe opiod-based meds for any patient pains but will not prescribe FDA approved meds for opiod withdrawal pains. They will get you hooked but they will not help get clean. I once took my daughter, a heroin addict, to a local hospital ER because she had come off the street and said she wanted to get clean. We sat in the ER room for at least 5 hours and we never ever saw a single doctor. After 5 hours, my daughter said dad I can’t take the withdrawal pains any longer. She then walked out into the darkness of night and we did not see or hear from her for a month. We lost an opportunity for sobriety. Further, as I am sure you can attest, every state has a Physicians Health Program (PHP) whose purpose is to treat addicted physicians. These PHPs have been around since the mid-seventies. According to a recent National Institute of Health Study, these PHPs have a success rate of over 70% so the medical profession knows how to treat addiction. Why won’t they share it with all the communities across the US struggling with the the opiod epidemic?
It’s doctors like you who saved my life by being able and willing to treat my substance use disorder. I have 8 years now in recovery because of my primary care doctor and his team of nurses and access to medication assisted recovery.
Thank you for treating this disease and giving me a chance to not have to live my shame and alone.
Agree with Paul’s comment. Julian Mitton’s views are inspiring and sorely needed.
Unfortunately our physicians have become drug dealers by over subscribing opioids. My son has a brain tumour and vp shunt, when he has crushing headaches his dr tells him to take Tylenol. So if that extreme pain doesnt require an opioid rx, why does my niece get oxy prescribed for a broken ankle (from falling off her high heels)! There’s a problem with Pharma companies and physicians freely providing these danger meds!
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