D

ear Doctor,

Please help me understand why so few of you have chosen to treat people with opioid addictions.

I’ve been following the topic of opioid addiction for years. It is one of the most common themes for First Opinion submissions. Authors routinely point to the importance of medication-assisted therapy, the standard of care for individuals with opioid addiction (a term that those in the know tell me I should replace with opioid use disorder). That means treatment with methadone, buprenorphine, naltrexone, or combinations of these — medications you could prescribe if you wanted to.

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The surgeon general’s report, “Facing Addiction in America,” says that medication-assisted therapy is effective in treating opioid use disorder, but is vastly underused. FDA Commissioner Scott Gottlieb has called medication-assisted therapy “one of the major pillars of the federal response to the opioid epidemic in this country.”

Yet 95 percent of you don’t prescribe these medications.

Why is that?

People with opioid use disorder are treated by family physicians in small towns, like Dr. Nicole Gastala in Marshalltown, Iowa, who was profiled in the New York Times. They visit psychiatrists in posh Manhattan offices. They see internists, gastroenterologists, neurologists, pain specialists, emergency physicians, and other specialists. In all likelihood, your patient panel includes one or more individuals with opioid use disorder, though you may not be aware of it — many people go to great lengths to hide their addiction.

Yet most physicians are standing on the sidelines and punting the treatment their patients need to someone else — or to no one. According to the surgeon general’s report, only 1 in 10 Americans with addiction are treated for it, and many of them get care that isn’t based on solid evidence. If that was the case for diabetes or heart failure or chronic obstructive pulmonary disease, there would be a huge hullaballoo.

I understand that methadone must be distributed in special clinics. That’s a big barrier for physicians who would like to prescribe it to their patients. A Perspective article in Thursday’s New England Journal of Medicine and a related First Opinion call for letting primary care physicians prescribe methadone, though that would take an act of Congress or changes to state laws to happen.

Buprenorphine and naltrexone are a different story. They can be prescribed and administered in virtually any primary care, mental health, or specialty clinic in a large city, a suburb, or a small town.

To a nonphysician like me, getting certified to prescribe or dispense buprenorphine seems to be a simple and straightforward process: complete eight hours of training and apply for a waiver. It could almost be seen as a twofer, since most of you need to accumulate continuing medical education credits and this training qualifies for CME. You don’t even have to take a day off to do it, as one of the training programs is a 4.25-hour webinar and a 3.75-hour online session.

Providing your patients with naltrexone is even easier. Anyone licensed to prescribe medications can prescribe this medication — no special training required.

I know your days are busy ones, often stretching far beyond your office hours and spilling into your evenings and weekends, sometimes crowding aside your time with family and friends. But given the scope of the problem — an estimated 2 million Americans addicted to opioids — isn’t there some way you can shoehorn in this training?

But maybe time isn’t the issue.

Why doctors don’t prescribe

In conversations with a number of physicians who prescribe medication-assisted therapy, I spotted several recurring themes of what might be keeping clinicians from joining their ranks.

Lack of training. During medical school and residency, you learned plenty about treating pain. You probably didn’t get any instruction about addiction, or treating it. “Physicians like to feel that they have mastered the skills they need to help their patients. This is one area in which most physicians don’t have mastery,” said Dr. Sarah Wakeman, medical director of the Substance Use Disorder Initiative and the Addiction Consult Team at Massachusetts General Hospital, and co-author of an article on buprenorphine in primary care in Thursday’s New England Journal of Medicine. It’s a must-read for everyone interested in prescribing this medication.

Getting the waiver. Under the Drug Addiction Treatment Act of 2000, physicians must get a waiver through the Substance Abuse and Mental Health Services Administration to prescribe buprenorphine to treat opioid use disorder. This sends a message that providing buprenorphine is something you need to opt into, rather than something you are expected to do. “Fresh out of medical school, you can prescribe for pain relief any of the opioid medications that can lead to addiction, but you have to get a special waiver to treat addiction, a disease process. That just doesn’t make sense,” said Dr. Sandeep Kapoor, director of screening, brief intervention, and referral to treatment at Northwell Health. “It really shouldn’t be that complex. Granted, more training is needed about addiction, but the stipulation of a waiver complicates much needed action.”

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Fear of the unknown. Some, perhaps many, individuals with opioid use disorder have other physical, psychological, and social issues — depression, anxiety, other substance use disorders, social isolation, unemployment, and the like — that complicate treatment. My guess is that your “regular” patients have these, too, and you are able to manage them. As I’ve watched family members and friends in the medical profession, they tend to take the unknown in stride and face these challenges.

Stigma of opioid use. Some, perhaps many, physicians choose not to offer offer their patients buprenorphine or naltrexone because of what Dr. Stefan Kertesz, professor of preventive medicine at the University of Alabama at Birmingham School of Medicine, calls the original sin: not seeing addiction as a brain disorder requiring treatment, but as a personal failing. Some physicians believe that medication-assisted therapy is little more than switching one addiction for another, a myth that Wakeman tackles in the NEJM article.

I’m sure there are other barriers. I’d be grateful if you shared them with me via our survey.

Why you should sign up

In medical school, residency, and on the job, you’ve learned many ways to help your patients stay healthy, recover from illness, and manage chronic conditions. Taking the small steps needed to prescribe medication-assisted therapy adds an extra skill to your portfolio. Letting all of your patients know you can do this may even prompt those who have been hiding their addiction to speak up and get help.

Dr. Marcelo Campos, a primary care physician at Atrius Health in the greater Boston area, decided to go public that he was certified to prescribe buprenorphine after learning that one of his patients, a 30-year-old personal fitness trainer, overdosed and died. “I never, ever suspected she had an opioid addiction,” Campos told me. “The day after I learned she had died, I went to the leaders of my practice and told them I wanted to start providing this therapy.”

Here’s another reason for prescribing medication-assisted therapy for your patients with opioid use disorder: it might be good for you. “Treating patients with opioid addiction has become one of the most rewarding parts of my practice,” said Campos. “Within just a couple weeks, I can see patients change for the better right before my eyes.”

If you are among the minority of U.S. physicians who prescribe medication-assisted therapy, please let me know through our brief survey why you’ve chosen to do that. If you don’t prescribe it, please take a minute through the survey to let me know why. Perhaps together we can identify other barriers that need pulling down.

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  • Contrary to what some advocacy groups would like the public to believe, addiction treatment is really not in the scope of practice for primary care providers. Individuals with opioid use disorder tend to have complex medical, social and psychiatric co-morbidity which complicates their treatment and contributes to poor outcomes and high mortality rates. The author’s contention that treating opioid use disorder is as simple as writing a prescription for naltrexone betrays his weak command of knowledge in this field–naltrexone is an opioid antagonist, unlike buprenorphine and methadone which are opioid agonists. Naltrexone has not been shown to reduce mortality in opioid use disorder and some studies suggest that mortality rates may increase with naltrexone.

    It is not politically correct to say so, but time-pressed PCPs are likely wise to avoid these complicated patients who in general are better served by treatment provided by an expert in the field.

    • Worse though are the general practice drs who assumes I am a complicated patient and fires me from their office without discussion

      See I have a mental problem from domestic violence of severe beating to my head, plus I have back pain from said beatings. However they assumed I’m a problem patient and fired me for being an advocate for my health

    • This sounds legit, however there are few ”experts” available. In a perfect world, one where a functioning healthcare system, afforded people access to experts and evidence based care, there would not be such a shortage. The System allowed this problem to continue to ensure corporate profits, and undermined any attempts to quantify it. The AMA and other entities decided not to even take continuing education classes on the issue, long before it reached epidemic proportions. At best all we can hope for is harm reduction. The “Addiction Industry” has not been particular beneficial either. In order to increase their market share, they have been misleading the public too.
      It looks like those of us who do not live in gated communities and have not lost our last shreds of humanity, will have to continue experiencing the carnage. I will remember this statement the next time, I get accosted by that poor brain damaged former addict. He shot up a concoction of alternate medications” given out by a Physician. They claimed these Anti Depressants, Anti Psychotics and anti epileptic drugs were a replacement for opiates. So a lot of desperate addicts injected them, and found death or permanent brain damage. No one counted these cases, Pharma marketed these as an “Alternative.”
      I will remember this statement the next time the Paramedics load up an addict, for one of many trips to the ER. They are “Stabilized” and kicked out untreated, because of industry interference in the ACA, and lack of profit potential.
      An “Addiction Specialist” or really anyone with an Education should be able to look at all of the equation, instead of jumping in to defend his field. There is no objectivity here, nor willingness to propose a compromise. It is all black or white. Besides even the “Addiction Specialists” are limited to a certain number of patients by law. The various industry lobbyists and insiders still see a profit potential here, so we don’t need to weight the damages. This only affects certain people in “those neighborhoods” anyway.

  • Why don’t I treat addiction? Same reason I don’t deliver babies or perform appendectomies. I became an internist not a psychiatrist, psychologist, MSW, or psych RN. My training, and interests, are in the management and diagnosis of disease. I enjoy managing sepsis. I’m interested in auto immune diseases. Helping a patient and their family transition goals of care to palliation and hospice is meaningful. I actually have a 1.1 full time equivalents appointment. My normal time is over time. I balance on the edge of burn out continuously. I would last half a week, tops, in addiction medicine.

  • They don t prescribe because it just may be that it does not show a demostatable response 6 months out and the provider investment is heavy

  • in Canada any doc can prescribe any drug. No DEA looking for scalps there. It is well known that you are under control of DEA treat addicts since otherwise is illegal. You treat addicts your supervisor is a federal drug police officer. Addiction clinics are therefore under more DEA scrutiny. Remove DEA from equation and I am good to go

  • Great article… I have been on pain meds since 2001 and struggling with it today. I have a full time job and all. Many doctors get scared when a person asks for help . I have know people who told their doctor that they are addicted to pain meds and they just cut them off and with no help. I have gone to doctors to try to taper off and they have tried to prescribe me fetynel and I refused and got yelled at . They tell me that they are the doctor and I don’t know what I’m talking about. It’s a really hard place to be when asking for help and getting looked at like I don’t know what’s going on. Also I hear that states are sueing the drug companies. So where is that money going… Not to help us get better or free treatment. So it’s really hard to get help when they are the one just writing prescription without providing more knowledge.

  • Don’t think that we have not been to the meetings, the long term and short term programs, the facilities, the courts (juvenile, child, and adult), the drug testing sites, and more. We have seen and experienced the lies of those who promise much and deliver little other than bills and more pain.

    Doctors are human – some are addicts, some are parents of addicts, some raise grandkids, and more. Some doctors are jerks, and doctors like me are tired of being considered jerks for some quirky reason or another. Misguided journalists are a particular pain.

    I grew up in a family practice clinic and this is all that I knew. That model is long gone – destroyed by slash and burn cuts plus killing costs of overregulation. This is happening at a time when complexity is going through the roof. Everyone reading this should understand just how complex it is to deal with any mental health issue – especially addiction.

    I work with the Center for Health Journalism and others to help them understand the situation across the American public being left behind. Clearly primary care associations, particularly AAFP, do not understand this and have made matters worse. We are losing in this battle of information – as seen in this article.

    I did solo rural practice as long as I could considering paid the least for primary care with 15% less for Area 99 in the lowest paid state and 15% cuts via the Reagan attack in 1983 on new physicians. Then the local economy and the payment design collapsed and there were no more choices for me or for my community. In primary care or as faculty also doing primary care it has always been the same
    Paid for 35 hours,
    working 60 – 70 hours,
    with stress of 80 – 90 hours.
    Everyone I worked with was dealing with the same constrained financial design – the same one that results in a few minutes of contact with your provider with them mostly at a computer screen.

    You are asking us to do much more with less and less, especially the practices where half of the US population has been set back with half enough primary care, mental health, and general specialty workforce by financial design. These are practices with the least payments, the lowest supports, the fewest team members, the most complexity, and the least local resources and facilities – and less of each with each passing year. And we are penalized, those that remain in primary care, just because we care for the most complex that have the worst outcomes – because they inherently have such outcomes.

    You could do a lot to help. You could file a report every time your insurance company jerked you around. State Health Insurance Commissioner sites have the forms. Before the insurance plans are approved, the companies are supposed to deal with these complaints. Do it. Make them work for you and earn their billions.

    • Amen. I’m sorry for my drs. I know the ins cos and government regulations are strangling what used to be care for sick ppl. Now I’m penalized for having multiple illnesses that make me “ special “. I hate to waste my drs time and go only when I’m really sick which is worse.

      I would prefer my old life and to give my little girl her childhood back. But we all are stuck

    • Oh stop with the whining. Every doctor I have known to whine has done well for themselves. It is your job to help the sick. Or should we change the oath to the hypocritic?

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