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.
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.”
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.