Despite efforts to improve access to a decades-old medication that can turn the tide of the opioid epidemic, the greatest challenge remains that doctors don’t want to prescribe it.
Cleared for use in 2002 by the Food and Drug Administration, buprenorphine is an opioid that can fulfill an addict’s craving but doesn’t deliver the euphoric high. Paired with counseling, the drug therapy is touted as one of the essential pillars in combating the opioid epidemic.
But it is unpopular among primary care professionals, who fear a patient base stigmatized as criminals and drug abusers will quickly dominate their practices.
“Many physicians would perceive that this is a population they don’t feel comfortable serving in great numbers,” said Dr. Charles Winfrey, a psychiatrist working in Virginia and West Virginia who prescribes Suboxone, the brand name for buprenorphine treatment.
“These are — many of them are street people with criminal records. I treat many felons on the outside,” he said.
Dr. Winfrey divides his work between his private practice in Virginia and the mental health department at the Martinsburg Veterans Affairs Medical Center in West Virginia. He is part of a push at the hospital to bring primary care physicians into the addiction treatment realm to increase the number of providers and expand access.
“What’s interesting and wonderful is you get them on Suboxone and, within a year, if they stick with the program, they’re back in jobs, they’re paying their rent and bills, their wives and children come back to them, everything comes back to normal, and that’s one of the most beautiful things I’ve seen,” he said.
An estimated 2 million people in the U.S. have addictions to opioids. For much of this population, their addictions started with an overabundance of pain pills after surgery.
The potent effects of medications such as OxyContin and Percocet changed receptors in their brains, directing them to demand more of the drugs. When the prescriptions ended and the black-market pills increased in value, heroin use surged.
Today, cheap synthetic fentanyl — 50 to 100 times more potent than morphine — taints nearly every illicit drug on the market.
A ballooning death rate from drug overdoses — nearly 64,000 people in 2016 — is set to get worse before it gets better.
In rural America, where the crisis has hit the hardest, family doctors and internal medicine specialists are often the only resources for addiction treatment, said Tim Putnam, the CEO of Margaret Mary Health Hospital in Batesville, Indiana, which provides services for up to 25,000 people.
“We’re used to treating acute disease, and we’ve got good programs in place for that,” he said. “But this crisis that we’re facing right now is causing us to create partnerships with organizations we haven’t worked closely with in the past. So it’s complex and has a lot of working components.”
In a community assessment survey of health care needs, addiction issues jumped to No. 1 from No. 7 over the course of three years, he said.
“We are not a community that has a high rate of addictions, but we are a very close community, so everyone who becomes addicted, every overdose, every death is a pretty devastating event for us,” Mr. Putnam said.
Restructuring care includes pairing Suboxone prescriptions with psychosocial treatment such as peer support groups and safe housing. Leading public health professionals and advocates identify it as the gold standard for opioid addiction treatment.
“Each physician employee should be able to prescribe buprenorphine (if that is the most appropriate treatment for the patient) in primary care settings,” wrote authors of the final report for the President’s Commission on Combating Drug Addiction and the Opioid Crisis.
“As President, you can make this happen immediately. We urge you to do so,” they wrote.
A number of changes over the past few years have removed important bureaucratic barriers, including easing restrictions for physicians to receive waivers from the Drug Enforcement Administration to prescribe Suboxone. The drug is a controlled substance and carries the potential for abuse, but the risk is low.
Reimbursement has been an issue. States that opted into Obamacare’s Medicaid expansion found coverage open up for a large number of the drug-using population that qualified under the new terms: those who are young and single and have inconsistent employment.
Caps on patient limits have improved. Doctors who receive the waiver from the DEA can treat 30 patients in the first year and up to 275 in subsequent years. Nurse practitioners and physician assistants also can receive waivers to prescribe Suboxone.
In total, there are 44,694 opiate treatment service providers, according to the Substance Abuse and Mental Health Services Administration.
However, Dr. Kelly Clark, president of the American Society of Addiction Medicine, said the actual number of specialists is about 3,000 in addiction medicine and 1,000 in psychiatry.
The tens of thousands of medical providers who can prescribe Suboxone have most likely received only about eight required hours of education on opioid addiction, she said, and “physicians really do not receive any significant training in addictive disease.”
Though they may be certified to prescribe agonist medication — drugs that block opioid cravings — and provide follow-up care, physicians might feel uncomfortable going that route after only a few hours of training.
These feelings were borne out in a 2016 survey by researchers from the Johns Hopkins University School of Medicine that sought to understand why buprenorphine was used infrequently in primary and psychiatry settings and among both waivered and nonwaivered providers.
Many physicians cited a shortage of time for more patients, scarce educational resources for treatment, a lack of social support for patients and inadequate reimbursement.
“There are payment barriers,” Dr. Clark said, “and one of the things we do in the U.S. is we put things into silos.”
If the mental or behavioral health part of an insurance plan covers addiction medicine, then there is little problem of reimbursement for a psychiatrist prescribing buprenorphine. Primary care physicians, however, may not receive the same payment because their specialty is not behavioral health.
Another significant barrier that the Johns Hopkins University researchers have observed is stigma — a lack of belief that agonist treatment works.
“When you’ve been diagnosed with a chronic disease, that’s a good time to look at taking medication,” Dr. Clark said. “But the majority of treatment programs in the country do not utilize medication for addiction. This is not true for psychiatry; that battle was fought and decided long ago.”
At the Martinsburg VAMC, the mental health department is working to identify “champions” in primary care who will take patients with opioid use disorder. They hope to begin a training session in August to give physicians the tools they need to feel comfortable prescribing Suboxone and detailing follow-up care.
“We’re really the people, in primary care, that have the emotional bond to the patients,” said Dr. Jonathan Fierer, chief of primary care at the hospital. He is joining the training session and working to bring in other physicians as well.
“We know their families and them, and we’ve been seeing them for a bunch of years,” he said. “We’re probably more likely to develop the rapport that would allow us to introduce the whole topic of Suboxone use.”
The VA in some respects is uniquely situated to build this type of program, with psychiatrists, social workers and primary care providers under the same roof.
Dr. Fierer said he was reluctant at first to take part in the initiative but has become more confident after working with the mental health services department, division of rehabilitation services and pain management program.
“When this got introduced to me … I reluctantly went along with it. But now, having looked into it a little more, I think it’s a great step forward,” he said.
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