Before the Covid-19 pandemic struck, the U.S. was making some headway in fighting the drug overdose epidemic. But as the nation directs scarce public health resources to combatting Covid-19, the number of drug overdoses has climbed to the highest level ever recorded. Between May 2019 and May 2020, more than 81,000 Americans died from overdoses, affecting millions of lives.
More and better treatment to stem the tide of overdose deaths is needed, but multiple barriers stand in the way.
Access to medication-assisted treatment such as buprenorphine, an evidence-based medication for opioid use disorder that is safe and well tolerated, is one key to ending the opioid epidemic. But treating addiction isn’t just about more doctors prescribing this medication. To truly deal with the root causes of the overdose epidemic, we must focus on the bigger picture about addiction.
Many people who live with addiction also have mental health disorders, which buprenorphine and similar medications do nothing to treat. Some experts argue that we shouldn’t require people to attend counseling in order to receive buprenorphine. And while forced counseling may not be a good idea, counseling that is appropriately matched to patient needs is a critical component of more holistic addiction treatment.
Many people with opioid use disorder have other complex social needs, such as homelessness, trauma, poverty, and other problems that cannot be alleviated with a simple prescription. They often need more intensive or more frequent counseling and a one-size-fits all approach of medication alone or medication coupled with just one type of counseling may not be appropriate or effective.
The opioid epidemic has been medicalized in part because the medical system is partially responsible for the epidemic: Overprescribing powerful opioid medications helped fuel the current crisis. Doctors have been called on to fix the opioid epidemic because they have contributed to it.
There has been, and will continue to be, an essential role for doctors to play in addressing the opioid epidemic through prescribing therapies such as buprenorphine. But they need to be better equipped to deal with it.
To prescribe buprenorphine, doctors currently need to get a waiver from the Drug Enforcement Administration, which consists of an eight-hour training that provides very basic information about opioid use disorder and its treatment. Many argue that this training is an unnecessary burden on doctors.
Responding to that sentiment, the Trump administration moved to eliminate this training requirement in one of its final policy directives. The Biden administration subsequently reversed course on that, suggesting that the Trump plan to eliminate the waiver to prescribe buprenorphine was issued prematurely.
I agree with the Biden administration’s decision to hit the pause button on eliminating the waiver process to prescribe buprenorphine. It provides doctors with basic addiction training they don’t receive elsewhere. And few doctors cite the waiver process as the main barrier to prescribing buprenorphine. Instead, barriers such as lack of time due to busy clinical practice, inadequate reimbursement for the time physicians spend treating patients with addictions, insufficient training about the biology and behavioral aspects of addiction, and stigma associated with addiction explain why only about 5% of physicians nationally have obtained the waiver to prescribe buprenorphine.
Doctors haven’t always agreed on what addiction is, let alone how to treat it. Addiction medicine wasn’t recognized as a medical subspecialty until 2015. Some argue that every doctor who wants to prescribe buprenorphine should be allowed to do so regardless of education or training.
We require doctors to have specialized training in other areas of medicine so why should addiction medicine be different? While any and all barriers to addiction treatment should be removed, treatment itself should be more wholistic than medication alone and that requires a well-trained, multidisciplinary team.
Addiction is a complex illness that requires more training, not less. Most medical schools do not include addiction-related competencies in their curriculum. This explains how celebrated physicians like surgeon Atul Gawande had no idea what they were doing when they inadvertently addicted patients by prescribing for them large amounts of opioids. This is why there have been recent efforts to integrate more training into medical school curricula to give future doctors the tools they need to successfully identify and treat opioid use disorder and other addictions.
Focusing solely on drug therapy to treat addiction ignores the crucial role other professionals, such as psychologists, social workers, counselors, and peer support specialists, can play in helping people recover from addiction. Current guidelines allow for nurse practitioners and physician assistants to obtain waivers to prescribe buprenorphine, though their required training is 24 hours compared to eight for doctors.
Disciplines such as social work and psychology have specialists in behavioral health treatments who are specifically trained how to engage patients around difficult topics such as drug use. Many of these specialists have addiction training that doctors don’t have. But they are often in short supply in primary care practices where buprenorphine is being prescribed to patients.
Many people do not feel comfortable talking with their doctors about sensitive topics like addiction and behavioral health disorders. Among participants in two national surveys, nearly half of respondents did not disclose to their doctor potentially life-threatening problems such as domestic or sexual violence, depression, and suicidal thoughts. Other patients are afraid their doctor will actively discriminate against them if they seek help for their substance use.
To improve addiction treatment, efforts should be focused in two areas. First, doctors would benefit from more training on addiction, especially related to patient engagement on topics such as drug use. Second, doctors need more help from other professionals who are highly trained in different aspects of addiction recovery. A multidisciplinary team approach to treatment should be the norm, not the exception.
Eliminating the limited education that doctors get in addiction treatment by cutting out the requirement for training to prescribe buprenorphine and pushing them to go it alone when treating patients does a disservice to doctors and patients alike.
Nickolas D. Zaller is a professor of health behavior and health education, director of the Southern Public Health and Criminal Justice Research Center, and co-director of the Rural and Global Public Health Program, all at the University of Arkansas for Medical Sciences.
Excellent opinion piece. I would add that STIGMA is a core obstacle to developing effective multidisciplinary treatment programs for addictions, including the stigma resulting from Federal cannabis prohibition that has prevented development of safe and effective non-opioid treatments for pain and OUD.