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Dear 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.

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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.

  • The A.M.A and various Doctors Organizations lobbied against Physicians taking Continuing Education for prescribing pain medication years ago. Their employers do not see much of a profit in Physicians learning anything about prescribing, drug addiction or pain management. The Opiate Epidemic is a result of this industry interference in Medicine. We live in a country where ethics and human decency are secondary to profitability. Besides all of the Patients left with Intractable Chronic Pain from surgical mistakes are easier to explain away by labeling them all addicts.

    • That statement is untrue. States decide what CME (continuing medical education) physicians have to take for licensure in that state. The AMA has no pony in that race. The AMA is society with dues that roughly 17% of the physicians in the US choose to belong to – and cannot dictate what CME is required, or even how much. States like WV and FL require 3 hours of CME in opiate prescribing. SVMIC malpractice insurance requires doctors they insure to take a minimum of 2 hours of CME in opiate prescribing. WV also requires CME in palliative care, part of which concerns opiate prescribing.

  • Now I get it!! This article was written by the editor of First Opinion of Stat., one of several addiction pieces by him. All articles resemble in tone the non MD’s who blame doctors.
    I am disappointed in you Stat for trolling physicians instead of reporting. Reporting would have involved you actually interviewing physicians to find out the constraints. But you don’t need to deal with truth when you troll. Surprise me and have the courage to publish and come clean with this game.

    Peggy Finston MD
    Acu-Psychiatry.com

  • I thank some of medical “ professionals” for their experience and information. I am saddened as 15 year clean and sober patient who is dealing end of life issues, to see how some think about the addicted “criminals “

    I was gang raped while pregnant and lost the baby, a year later I lost my mind. I was sent to a psychiatrist who loaded me with meds every time I saw him. Seroquel, Xanax, bus par, dalmane, prozac… all in a 2 month period. I stupidly went cold turkey off them because of how I felt and he insisted to go again. Anyway a few years later i ended up in a 12 step program that saved me. I don’t judge those who need MAT, although I don’t want it. If I ever lose this pain I will follow my dr whom I tell everything

    I’m grateful she is more open minded than certain posters here. You ma’am are why people hide their needs.

    • I forgot to add (I was so upset earlier about reading the thread).

      I got clean and sober cold turkey in a 12 step program almost 16 years ago. What works for me may not work for others , I’ve seen very few MAT recovery in the program as it’s so looked down upon by people in the groups. There’s no rules in a rogram but people tend to be snobs about any meds which hinders a lot of people seeking psych help, surgery or various aging disorders.

      I say this for y’all to understand how much we care about our sobriety, our impact on others and the way people understand addiction.

      No one grew up saying I want to be a junkie. I’ve seen just under 98 people in 15 year , these were close friends they succumb to this while trying to make it

      It’s unknown about those who came and left the first week. You Drs would be welcomed at any Open meeting so you might grasp the other side of who and what we do. We aren’t the criminals that psych called us. I’m sorry to see how y’all feel about patients especially psych patients. Your terrible advertisement for people to seek help!

    • Hey Cindy! Great posts. Recovering junkie here. Absolute zero, nada, nothing from physicians in the form of help. They are awful. Very sad so many docs still think addiction is a moral failure. The same docs that are out getting hammered and bumping a few lines on the weekend. Incredibly ignorant and usually not very bright.

  • We were bombarded with the “Just Say No” campaign in the 80s. Billions have Been spent on this so called Drug War. Yet Purdue’s offices will not be raided by the DEA! In 2016 there was close 20,000 deaths due to opioid overdose! Bob Forrest, the Chemical Dependency Program Director at Las Encinas Hospital, warned this nation about opioids as being a new gateway drug in 2011. This is out of control! This Government allows these companies to kill thousands yearly, in addition to making it nearly impossible for the addict to get proper treatment for opioid addiction!

  • Were it so easy to become an opiate use disorder prescriber. In every state I have a license in, to prescribe suboxone or methadone for opiate use disorder requires a huge commitment in time, money and resources in order to prescribe one medication. It requires additional education – a time commitment up to 100 hours of CME in one state where I am licensed, with additional licensing required. All of that costs thousands of dollars up front, plus time lost from work, plus the cost of setting up a valid REMS program (Risk Evaluation and Management Strategy) that requires hiring additional certified staff, drug testing kits and additional malpractice insurance for treating those patients. Furthermore, initially you are only allowed to have 30 patients the first year if prescribing suboxone. The ability to treat more patients is determined by regulating entities, and is capped at 100 patients per physician. The time commitment is considerably beyond what most physicians can afford.

    If regulations allowed all primary care physicians to prescribe methadone without some intensive training and guidelines, then the dangerous effects of methadone may prevail. Life threatening respiratory depression when mixed with alcohol, benzos, barbiturates, other opiates, extremely prolonged QTc, accidental pediatric overdose and deaths (which I have seen), CYP450 interactions that can cause fatal overdose or lack of effect, and serotonin syndrome when added to other serotonergic agents such as tricyclic antidepressants and SSRIs.

    I know everyone wants to blame doctors for the opiate crisis start to finish. The truth is, if “Pain Is the Fifth Vital Sign” had never been published, we wouldn’t be here today. In 1997, that paper caused many physicians to be reported to state medical boards and even sued, because patients felt their pain was under treated without regard to what was causing the pain, or the risk that some patients are not good candidates for addictive medications. “Pain is the Fifth Vital Sign” also spurred a tremendous amount of research using opiates to treat non-cancer pain. Those studies id not reflect how opiates would be used in the majority of patients since those studies were highly selective for motivated patients who wanted a return to function. Furthermore, the studies were of short duration. Those studies opened the way for pharmaceutical manufacturers to forge ahead, churning out all types of opiates.

    The next big force was Press-Ganey scoring thanks to the ACA, wherein doctors and hospitals found their paycheck cut for unfavorable patient reviews. Suddenly, many PCPs were faced with a 2% loss of income if their patients weren’t happy. Since opiate prescriptions made people happy, the number of prescriptions soared after the institution of Press-Ganey. (None of which ever made sense to me since only politicians and beauty queens get paid for popularity. Everyone else gets paid by work performed and promotion comes from merit.)

    Another problem you don’t consider is that buprenorphine and suboxone have both become drugs of abuse. In WV we saw a lot of pregnant women hooked on those drugs without valid prescriptions.

    So what IS the answer? Free naloxone training for physicians, tort reform or malpractice protection so that when addicts don’t heed the warnings not to mix their methadone with any other CNS depressants or they begin abusing their suboxone and improve/standardize reimbursement for treating those patients would be a reasonable place to start.

    During my 26 years as a physician treating the indigent, I have noticed that every time the federal government intercalates itself between patients and physicians, it generally creates terrible problems with care. Add to that, the Joint Commission making policy often without sound science behind those proclamations, we will continue to make healthcare more and more expensive.

    A tremendous amount of the cost of our healthcare in the US is due to the non-medical/administrative requirements. Hospitals are top-heavy administratively and those salaries are enormous compared with what physicians make.

    • Arizona has new state laws that require substantial paperwork. There are new forms to fill out to prescribe any narcotic (from codeine cough medication to most of the medications used for addiction treatment). One standard form is filled out that is supposed to predict the risk of addiction and includes a screening question asking whether the patient has a history of Preadolescent Sexual Abuse. The other is a consent for opioids that all must fill out and get signed. Minimum extra time is 8 minutes for the physician and the questions are likely to trigger other discussions that will take even more time. Another 8 min will be required for processing to take paper to be documented into the electronic record. The results are quite predictable. Fewer who need medication will get it and more who need treatment will not get treatment. The burden will fall upon fewer who will do worse financially.

  • How many of those untreated drug addicts has good healthcare coverage? Our medical system incentivizes doctors by paying them more for treating people with good, private healthcare.
    Follow the money and you will likely find your answer.

  • I wish everyone would take a step back and look at it from the other’s perspective. I have had the experience of being both a patient and a health professional and if both patients and providers could see for themselves all the processes, concern and worries each other goes through they may have more compassion for each other. I know a lot of physicians who have gone through their entire medical training and never had an injury or illness requiring months of appointments, blood draws, painful or uncomfortable procedures let alone a hospitalization or surgery. Perhaps if every medical student was required to have a leg put in a cast and spend several days in the hospital and experience daily multiple blood draws, 5 or 6 AM rounding by physicians or surgeons, getting out of bed to go to the bathroom and physical therapy they may have a different view. Hopefully actual medical students undergoing C-section would empathize with the pain felt when needing to get up to tend to the baby or getting to the toilet and the anxiety felt when a nurse can’t immediately get to your room to bring your pain medication timely. Perspective can be enlightening.

  • I’m sorry, but those of you who think doctors have a “say” in what they do are seriously out-of-touch with what’s happening in healthcare. You think doctors have a choice about a 15 minute med check? Wrong, that’s set by the facility, CMS. and insurance companies (If you go over 15 min., spend extra time with a patient, you are judged “inefficient” and risk loosing your job.) You think doctors have a choice about what labs to order or what drugs to use? Not Really. Only if they are already pre-approved. Any deviation will require oodles of paperwork/telephone time, and the answer is usually no.
    You think doctors are avoiding treating addicted people? Treating addiction is not a “one-man show.” Takes more than a pill. It takes a village. A Script without the village, and I mean a good village, puts that patient more at risk. That said, do you know what risks a doctor takes on when treating those with addiction? Some risks involve personal safety. Those addicted can be serious criminals and doctors will likely be seeing them in understaffed circumstances. Some risks are medical-legal and can go one for years before resolution. Doctors can be construed as culpable for what choices addicted patients make when they leave the office and what they do to others.

    Don’t swallow the Madison Ave drug hype. It takes more than a pill to recover from anything, especially addiction. Suboxone is no miracle in the wrong circumstances. Without a supportive community that is monitoring that patient 24/7, he will trade those “Subs” for his drug of choice.

    In summary, doctors are not in charge. They don’t make the rules, anymore.
    They are not rolling in money, but in despair. In fact, some kill themselves, like this year, throwing themselves off NY hospitals. The why is not mysterious. That’s what some people do when their purpose/goals in life are being trashed.
    How did the Vietnam vets feel learning about the anti-war protests?
    If you want to protest, take it up with your insurance company or your government and vote carefully. I am not saying all doctors are good or honest, only that those who have replaced doctors in making critical decisions are worse than dishonest or bad.
    They are ignorant. They don’t get sued and they have no accountability.

    Peggy Finston MD
    acu-psychiatry.com

    • Just to get this straight. I would NEVER choose to see you or anybody in your practice. You are angry and nasty, not even civil. Maybe some patients will see your online presence and never see you again. Have you thought of entering a profession where you do NOT have patient contact? And you are in psychiatry? Hmm… compassionate, NO!

    • It is indeed sad that people fail to see what is happening. The revenue to support a practice is going down the tubes. The costs of delivery are being accelerated, particularly by meaningless regulations that have yet to demonstrate anything but higher cost and greater complexity. Failures exist across small practices, small hospitals, primary care, mental health, women’s health, and basic surgical workforce where half of Americans are found – the ones stuck with the worst public and private insurance plans and generally the worst of the mental health “coverage.”

      This same discussion came from physicians blamed for not taking Medicaid – but there are reasons such as actually having a practice at all.

      Insurance companies are constantly killing off those who do mental health care. Imagine caring for someone for months and then the insurance company says it was not needed and then a discounted $30,000 payment was clawed back – despite the fact that your facility did all asked. Records are lost and payments are not made involving thousands – fortunately emails were found and they were forced to pay. Addicts finally show up for treatment and somehow have coverage, but United says their computers are down – knowing full well in a few hours that the person will be desperate for a fix or something and will leave.

      The state of Nebraska only funded 10 or 11 months of mental health care for some facilities that eventually closed. They dumped their long term hospitals even though advisors and consultants told them it would cost far more for counties, sheriffs, state troopers, and people because of the situations that would develop, plus increased costs of health care, emergency rooms, and more. But dump they did.

      There are entire health systems, most respected ones, that have had fines and discipline for not doing
      reasonable mental health investments – and yet they continue to do this. It is a best way to dump patients with complex needs and high costs while keeping outcomes high and costs low.

      Treatment facilities find innovative new ways to get rid of Medicaid patients as soon as possible, even by verbal or other abuse.

      The DEA wanted to send a drug company or drug distributor CEO to prison to set a chilling example that would stop rampant “legal” drug sales and distribution – for profit and for addiction. The CEOs won. Congress passed laws virtually preventing accountability. Now 46 former DEA agents work for legal firms as consultants to keep DEA at bay (CBS 60 min, Whistleblower).

      The real world is quite different than the speculation of a journalist.

    • Sorry can’t call you a Doctor, you are one of the problems with helping US “ADDICTS”, we are not addicts we are opiate dependent.as you said,do you know what risks a doctor takes on when treating those with addiction? Some risks involve personal safety. Those addicted can be serious criminals”, CRIMINALS, So you only got Into medicine for the $$$$ I have read your words. But in truth it was the doctors of my State who are criminals, they are the ones whom prescribed the pain meds by the hundreds every month to people for profit , 240 30 mg oxycodone and 120 15 mg oxycodone and 90 Xanax to one person ? And I have been clean for 8 years and went trough complete hell , sorry Finston it doctors like you who make it hard for us to get help!! And just because you hold a license , Doctors care about their patients and communities and I see you don’t care only steoro type us, what a shame you are to even call you Dr, please go to a NNA meeting a few times and see what we go through ad who others look at as because of so called doctors like you, to all you needing help don’t give up there are Great Doctors out there like my own brother who cares about his patients and never has once judged anyone with any kind of addiction , one thing he was educated to know it’s a brain disease , not a moral issue or we are not criminals we are the victims from doctors, think about that. God Bless you Doctors who sacrifice to help someone like me, and to all who have asked for help.

  • Pity they weren’t so reticent about getting people addicted in the first place. Doctors act in their own best interest, not yours. Not all maybe, but most. Why do people assume otherwise? I don’t get it. Is it the cultivated bedside manner that fools you? Get over it. It’s fake.

    • Duncan, doctors didn’t want to prescribe opioids so freely; and they weren’t getting kickbacks from the drug companies- that was always monitored and illegal.

      The truth is, as Dr. Finston alluded, that doctors like myself were forced to over-treat pain. The mid-1990’s saw the perfect storm of a flawed pain-scale, a JACHO mandate that all pain be (over) treated, and threats on physician practices for non-compliance.

      I recall the night in the ER I was personally coerced then threatened by a nursing supervisor to continuously provide pain medication to a young man for shoulder pain with no objective findings; I fear that young man has succumbed to opiated abuse, but I know JACHO and Hospital metrics were to blame.

      To solve the crisis will take major investments in detox centers with multi-disiplinary services and, most importantly, patients that WANT to detox.l; many are just seeking to continue their habit – be it illicitly or through maintenence programs like this article is offering as a cure. Know that there is NO PILL SOLUTION TO ADDICTION. It doesn’t work for smoking, nor obesity, nor opioids, etc.

    • Opioid agonist treatment of opioid addiction reduces mortality. Systematic reviews of randomized trials consistently show a wide range of improved outcomes. That’s probably as good an indication as any that they work, or at least that they work as well as other medical treatments do for other chronic diseases. #factsmatter

    • Happy to see any high quality studies not run by those marketing drugs – studies that demonstrate significant success in addiction treatment involving populations and places where half enough basic health workforce exists – populations with stagnant to declining economics and the worst public and private insurance plans where there are the fewest programs, facilities, or treatment programs.

    • Having access to care reduces mortality and improves outcomes in many studies. It is not necessarily about the access. It is about differences in the populations. As has been noted, it is hard to access the medications for treatment. Those who can access the medication are different than those who cannot.

      You are right to focus on access, but there are many many factors that shape access or lack thereof. There is an entire span of years or decades that shapes the events and outcomes. The tail end is often all we have for treatment, but outcomes are limited by the years and decades before and the months and years after.

      Americans that lack access lack many other areas. You may be in a better position than most who lead health care to understand that populations with better social determinants (jobs, income, housing), situations, environments, conditions, resources, and family structures do better and can get more done.

      I tell the primary care leaders the same over and over again. They want to claim primary care causes improved outcomes. Like this is possible in the 0.6% of waking minutes in a year in a primary care office with most of this time with the physician interacting with a computer screen.

      Correlation is not causation. Associations do not shape outcomes. Just living in a place with higher to highest concentrations of primary care is not enough to indicate causation of better outcomes. I similarly have to point this out to others. The primary care leaders believe what they want to believe – cherry picking what they like and rejecting what they do not agree with.

      Decades of divisions have shaped the opioid impact as with maternal mortality, infant mortality, and longevity worsening.

      You are rightfully upset at so much done for so few leaving little at all for most Americans – little workforce, little access, worst plans, least health dollars spent locally, fewest health care jobs, and concentrations of health care providers with the least support.

  • One more thing. A brief perusal of the attitudes, approaches and opinions stated on this thread may explain in part why patients suffering from addiction don’t disclose that or seek help from physicians.

    • Although there have been some comments that demonstrate limited knowledge of the evidence for opioid addiction treatment, I think quite a few primary care providers responded with detailed information about why they are not able to provide treatment to this complex population, which is after all what the author requested. Criticizing them for their candor about the systemic barriers to providing treatment seems a bit harsh.

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