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.

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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.

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  • Hi
    I fully concur with all you’ve stated in your article. I recently retired reluctantly at age 80, but became a consultant to the U.C.R.School of Medicine on proper use of M.A.T. & M.A.R. blended with the A.S.A.M. proper intake Criteria of Care!
    I agree that the physician population is reluctant to treat due to multiple concerns.
    Thanks🙏

  • The formula for getting more prescribers to treat the epidemic AND eliminate/mitigate stigma is really quite simple: incentivize people to treat through enhanced reimbursement for these services. Pay them and they will treat – it ended the stigma around the AIDS epidemic and can do same here!

  • The AMA was against education or treatment for addiction. It was most likely a financial decision, like all of them. This discussion really should have been done 15 or 20 years ago, but the powerful AMA, blocked the conversation. In the US, people are being Gas Lighted by industries, with only one goal Profit.
    There is an incredible amount of misinformation, lies, and propaganda, surrounding this topic. A fact based scientific approach would have stemmed this problem years ago, instead we got pharma marketing from corporations like Purdue. Physicians did a cost benefit analysis, and due to the actions of various, lobbying interests, decided they did not have to address this issue.
    In the US major health providers are religious non profits, they were supposed to provide “community based care” to maintain their status. In order to keep the money flowing in they found that stigmatizing the addicted, and billed govt insurance for repeated ER visits, and the myriad hospitalizations, of the addicted. The refusal to respond was just more profitable. Due to “religious concerns” they could stigmatize and blame addicts, while at the same time profiting from repeated expensive hospitalizations.

    Here in the US the only focus of the healthcare system is increasing market share, and profit. In order to keep this up, they keep the public in the dark. The Customer Satisfaction Surveys are a really useful way to keep the public misinformed. They typically only rate the niceness of the staff, not the quality of the medical care. There is no check box on the survey, for a physician unable or unwilling to use medical records, misleading statements by staff, as long as the worker is “nice.” There is no box to check for repeated vistis for the same thing, or a misdiagnosis. As long as the misdiagnosis is delivered nicely. These surveys were designed to mislead.

  • We have many little children in our waiting room; including newborns and frail elderly by themselves with no supports. Weapons, foul language, and threats of physical harm are commonly used when an addict is refused a request for drugs. Your argument is for better addiction facilities, both detox and 12 step; not to subject non-addicts to street violence.

    • Rosemary,

      The stigma surrounding addiction, is very misleading. You immediately visualized the “Great Unwashed” or street level addicts/poor people/homeless.
      There are so many addicted people, many of them would appear normal to you. They are middle and upper class people, with jobs. It is exactly that attitude that has kept this country from adequately addressing the issue of addiction.

  • This is a strangely titled article. Clearly the author has good reason to wish that more physicians would opt to treat opioid addiction. But there is NO good reason that most physicians can think of to treat a disease for which they were likely not trained, that (to be done properly, with assistance medications) requires that they do additional certification and testing to get a federal waiver to use them, and then undergo increased scrutiny by regulators regarding any medications they dispense, and that can (as illustrated) cause disruption in waiting rooms and discomfiture for other patients, and can even cause the physician to risk their own life and that of their staff in a variety of ways, is far from a business reason. The opposite seems to me in fact to be the case: in my opinion, it is an almost exclusively personal, and prudent, decision.

    • You are right! There are physicians sitting in prison right now, for prescribing Methadone.

    • The problem we’re having in the USA is medicine has become fragmented. Physicians are not welll trained to care for the sick especially the addicts. Without pharmaceutical, what kind of compound a physician can offer to treat his patients?

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