‘Gold standard’ underused for substance misuse

Rates of opioid addiction treatment in primary care remain distressingly low in the United States. Fixing that might require a wholesale reimagining of how opioid use disorders should be viewed as well as managed.

“The treatment of substance use disorders is highly segregated in our system. If we are really going to make a dent in treating opioid use disorder, we really have to rethink the way that we deliver care. We need to bring treatment for opioid use disorder into mainstream health care,” said Chinazo O. Cunningham, MD, MS, associate chief of the department of medicine in the division of general internal medicine at Albert Einstein College of Medicine in New York City.

Internists are already seeing people with opioid use disorder in their practices, perhaps even at higher rates than they might expect, said Jeffrey H. Samet, MD, FACP, chief of general internal medicine at Boston Medical Center and Boston University School of Medicine. National surveys conducted via household interview show a prevalence of 1% to 2% for opioid use disorder among adults in the U.S., he noted. However, in a study in Massachusetts published in the American Journal of Public Health in December 2018 that used capture-recapture methodology, he and his colleagues found a prevalence of 4.6%.

But even though they care for patients with opioid use disorder, primary care physicians face several barriers to treating their addiction.

Still a stigma

While effective medications to treat opioid addiction are available in primary care, many doctors don't prescribe them, and many don't want to.

In a survey of primary care physicians published April 21 by Annals of Internal Medicine, few reported prescribing buprenorphine (7.6%) or naltrexone (4.0%), and few (11.8%) expressed interest in obtaining the Drug Enforcement Administration (DEA) waiver for the former. Fewer than half supported allowing physicians to prescribe methadone in primary care settings (47.7%) or eliminating the buprenorphine waiver requirement (38.0%).

“Only about two-thirds of those primary care physicians thought that treatment of opioid use disorder with medication is more effective than treatment without medication, which is in conflict with the gold standard guidelines,” said lead author Emma E. McGinty, PhD, MS, a faculty member at Johns Hopkins Bloomberg School of Public Health and Johns Hopkins Center for Mental Health and Addiction Policy Research in Baltimore. In addition, she said, “We found that very few physicians, including those who recognized that medication is the most effective treatment, reported an interest in treating patients with opioid use disorder. So that might provide some clues that primary care physicians feel like substance use disorder is outside of their purview and belongs in specialty care.”

Dr. McGinty speculated that the results might be related to the longstanding history of abstinence-only treatment for addiction in the U.S., fed by the unsupported claim that using an opioid agonist, such as methadone or buprenorphine, just replaces one addiction with another. This belief, Dr. McGinty said, “perpetuates the myth that addiction, of all chronic diseases, is a personal choice or a moral failing, not a brain disease or health condition at large.”

According to Erin E. Krebs, MD, MPH, FACP, of the Minneapolis Veterans Affairs (VA) Health Care System, another common misbelief is that opioid use disorder is most often seen in patients addicted to illicit drugs. But in her practice, she said, she is more likely to see people who have chronic pain and have developed problems with prescription pain medications. Specialty clinics aren't usually geared toward caring for patients whose problems developed with treatment for pain, she said. “That is an important need that primary care is best suited to fill.”

Treating opioid use disorder in primary care is akin to treating patients' more traditional chronic conditions, the experts said. “But how to do that, especially when there are a lot of hoops that we have to jump through to get it done, is a barrier really to expanding use of the medicines for more patients,” Dr. Krebs said.

“What we also know is that by treating a patient in primary care, we also improve other outcomes for patients, not just their drug treatment outcomes,” said Dr. Cunningham, who heads her facility's opioid use disorder treatment program. “So we improve hepatitis C outcomes, we improve HIV outcomes, and so it's really about treating the whole person in primary care. And by ignoring an opioid use disorder, it's very likely that people are going to have difficulties managing their other illnesses.”

Another barrier involves a potential lack of successful positive experiences, Dr. McGinty said. “Physicians, like everyone else, are more likely to endorse the effectiveness of things that they have seen work in their own experience,” she said. “But if they haven't been prescribing, which many of them haven't, I think it's easy to state that, ‘Oh, medications are no better treatment than without medication.’”

Dr. Krebs added that many primary care doctors may have patients with opioid use disorder in their practice for whom they have been providing opioid analgesics. “They may have known these patients for many years and have been prescribing for them for many years and have a certain amount of heartburn about it—that feeling in your gut that you're not helping somebody, but you don't know how to get off the path that you're on,” she said.

Changing these attitudes will require a cultural shift in thinking about treatment for addiction, said Jeanette Tetrault, MD, FACP, program director for the addiction medicine fellowship and co-director for the Addiction Recovery Clinic at Yale University in New Haven, Conn. “We talk to providers who say, ‘Despite treatment, the patient had three urines that were still positive for opioids, so we're going to take them off their buprenorphine,’” she said. “It doesn't make sense to punish by stopping treatment if they are showing ongoing signs of the disease.”

She also noted that it is not uncommon for both patients and the medical community to judge the success of treatment for opioid use disorder by when the patient is able to stop medication like methadone or buprenorphine. Other chronic conditions, like hypertension and diabetes, aren't judged that way, Dr. Tetrault noted. “I spend a lot of my clinical time practicing in an opioid treatment center, and the first question a patient or their family member will ask me after starting methadone is ‘When can I come off this?’”

Physicians can prescribe morphine, oxycodone, and codeine without special training or a DEA waiver number, but they can't provide buprenorphine, even though it is safer, Dr. Cunningham said.

“I think that's a level of policy that's important: requiring or not requiring a special DEA number,” she said. “Buprenorphine is the only medication that requires special training in this country. … Again, I think it's about stigma. There's no evidence that supports needing to do special training to provide buprenorphine treatment when, in fact, because of its pharmacologic properties, buprenorphine is a much safer opioid than all the other opioids that are prescribed.”

Dr. Krebs added, “I feel like the [DEA waiver] training doesn't tell you what you need to know. It's very heavily [focused] on medical-legal. And I found that a lot of primary care physicians I've talked to feel kind of put off by the training and also feel like they don't have the practicalities they need once they've completed it.”

Educational gaps, resources

In general, substance use disorder isn't a robust part of medical education, experts said.

Dr. Tetrault said that medical school training on addiction may be integrated with public health or psychiatry, with anywhere from zero to 10 hours over a four-year curriculum. But she and other experts don't feel that's enough, especially given that substance use disorders are associated with more than 90 other medical conditions seen in primary care.

“I had in my four years of medical school one hour of training on substance use disorders, one hour in four years,” Dr. Cunningham said. “Why do we learn about diabetes and cancer and heart disease but not about substance use disorders?”

When Dr. Tetrault finished her residency in 2004, the field of addiction medicine didn't exist. Now, there are 92 fellowships available, she said. But she believes addiction medicine training should be incorporated throughout the medical school curriculum in tandem with other conditions rather than isolated in its own course or discipline.

“The bottom line is we have an opioid epidemic on our hands and one in 10 people with a substance use disorder don't receive any care, and it's really up to all of us to have a part in addressing it,” she said.

Dr. Krebs cited resources available through the Providers Clinical Support System that can connect physicians newly trained in buprenorphine prescribing with more experienced “mentors” to guide them. In her own early days of prescribing, she said, she relied on another VA physician for advice.

“I was texting him, you know, asking him questions like, ‘OK, how many pills do I give for the first prescription? How many days' supply?’ Really basic questions like that that just don't make it into the waiver training but are the kinds of fundamentals that you need to know to actually practically do it,” she said.

Other educational efforts in real-world practice can also yield results. Dr. Samet's group published a study in the Journal of Substance Abuse Treatment in June 2015 describing a Massachusetts Bureau of Substance Abuse Services initiative that disseminated information on office-based treatment with buprenorphine to 14 community health centers beginning in 2007. Nurses working with physicians played a central role in care, and the model increased the number of physicians who received buprenorphine waivers from 24 to 114, up 375% within three years.

Workshops on addiction medicine and buprenorphine treatment, like those offered at ACP's annual meeting, can be another resource, said Dr. Samet, who has spoken at some of them. “I think those type of workshops are terrific, because you get someone who's kind of interested but didn't really know how to do it, and they go to the annual meeting, and they say, ‘Maybe I can do this,’” he said.

That realization that addiction care is primary care is key, according to Dr. Tetrault. “It doesn't have to be outside of the medical treatment world; it doesn't have to be by a highly specialized physician,” she said. “There are things that can be done in the primary care setting very easily that could change a person's whole life.”