One morning last week as I arrived at our new addiction treatment center, the CAPA Clinic in St. Louis, one of the social work student interns I supervise couldn’t wait to tell me about the “excitement” they’d experienced in the few hours the clinic had been open for the day: a patient had been stabbed, another was screaming in the waiting room and had to be removed by the police, and detectives arrived to arrest one of the clinic’s clients.
That got me thinking about my participation in a national panel of addiction experts whose work formed the basis for “Medications for Opioid Use Disorder Save Lives,” a new report from the National Academies of Science, Engineering, and Medicine. In it we noted that, despite the huge need for U.S. physicians to provide medication-assisted therapy for opioid use disorder, only a small number of them have signed up to do it. The panel recommended that more join in.
More than 2 million people in the United States have an opioid use disorder, which is caused by prolonged use of prescription opioids or illicit ones such as heroin and fentanyl. Opioid use disorder is a serious chronic illness — individuals who suffer from it have a twentyfold greater risk of early death due to overdose, infectious disease, trauma, and suicide.
According to the National Academies report, the current Food and Drug Administration-approved medications for opioid use disorder — methadone, buprenorphine, and extended-release naltrexone — are safe and highly effective medications for its treatment. These medications can ease or banish withdrawal symptoms and reduce cravings for opioids, which helps people lower their rates of relapse and avoid fatal overdoses.
The hubbub in our St. Louis clinic, a partnership between Washington University in St. Louis and Preferred Family Healthcare, brought home to me why some primary care physicians might be reluctant to take on the responsibility of providing medication-assisted therapy to their patients with opioid use disorder. A First Opinion in STAT last July listed a number of reasons physicians aren’t stepping up to treat people suffering from opioid use disorder. The National Academies committee addressed some of those reasons, such as the lack of specialized training in medical school and the process for getting a federal waiver to allow them to prescribe these medications. We also discussed the possibility of deregulating buprenorphine prescribing.
From my perspective as someone who entered the treatment industry as a patient in 1989 and who has remained in this space since then as a therapist and later as an academic, the stigma of addiction — or more specifically its branding — is powerfully negative. Physicians whose practices focus on patients with opioid use disorder don’t have to worry about their “brand” being harmed because it is tied to this treatment and this patient population. But a typical primary care physician in Manhattan or suburban Atlanta or rural Nevada might worry about the potential trouble that patients with addictions might cause in their waiting rooms.
With primary care’s business model relying on patient satisfaction, a small issue like patients getting upset and protesting which TV channel is playing in the waiting room could significantly affect a physician’s bottom line.
The stories coming out of treatment programs across the country reveal the devastating consequences stemming from opioid use disorder. Patients are overdosing in program bathrooms and waiting rooms, or in their cars in treatment center parking lots. There’s the kind of low-grade mayhem that occurred recently in the CAPA Clinic. For those in the addiction treatment industry, these are unfortunately commonplace stories that come with the territory.
Would successful physicians be willing to jump through all of the additional hoops needed to prescribe medication-assisted treatment, including additional training and monitoring by the Drug Enforcement Administration, to stake their brands or businesses in order to take on this high-need, stigmatized population?
A few may, but I can’t see the majority of them doing that.
There is a reason that methadone clinics are mostly out of sight from the general public. “It’s not personal. It’s strictly business,” according to the famous saying in the movie “The Godfather.” What I have learned during almost 30 years in this space is that when it comes to addiction treatment, especially during this opioid epidemic, it is both personal and business. When individuals and families are personally affected by the disease of addiction, such as losing a loved one to this illness, they sync with the belief of the National Academies committee that we are in an all-hands-on-deck situation.
But having just finished Chris McGreal’s book, “American Overdose: The Opioid Tragedy in Three Acts,” I’m coming to believe that the business side of the opioid epidemic might be the most powerful reason why so many practicing physicians remain below deck.
David A. Patterson Silver Wolf, Ph.D., is an associate professor in the George Warren Brown School of Social Work at Washington University in St. Louis, where he is a faculty scholar with Washington University’s Institute for Public Health and also serves as a faculty member for two training programs funded by the National Institutes of Drug Abuse.