Why do we continue to allow our front-line primary care physicians to avoid being involved in the care of their patients with addictions?
“I’ve had conversations with a few hundred primary care doctors to try to figure this out,” said Dr. R. Corey Waller, an addiction-treatment specialist who leads the advocacy division of the American Society of Addiction Medicine, or ASAM. “I get comments like, ‘I don’t want those people in my waiting room.’ Ones who are more well-meaning — which is most — say they have no training to treat this disease.”
StatNews.com reporter Bob Tedeschi wrote a very comprehensive piece published yesterday, October 19, 2016 entitled “Watching the ship sink’: Why primary care doctors have stayed out of the fight against opioids.”
In the face of one of the country’s most pressing and fastest-growing public health crises, few primary care doctors treat substance abuse disorders, even though they are uniquely positioned to recognize problems and help patients before it’s too late.
Instead, many primary care doctors follow an old script: Refer patients to addiction centers and Narcotics Anonymous, and move on.
“We’re just watching the ship sink, even though we have the pumps to easily keep the water out,” said Dr. R. Corey Waller, an addiction-treatment specialist who leads the advocacy division of the American Society of Addiction Medicine, or ASAM.
Michael Botticelli, the director of the White House office of national drug control policy, agreed, describing the absence of a more vigorous response as “deplorable” during a recent forum on the opioid crisis in Albuquerque.
The federal government last year embarked on an effort to double the number of doctors certified to treat addiction with buprenorphine, a drug shown to curb opioid cravings in most patients. That effort has yielded some early success, but according to ASAM, less than 1 percent of primary care doctors are now certified.
There are few incentives to get trained, however, especially in the many states whose Medicaid systems do not reimburse physicians for addiction treatment.
“A lot of people want to malign primary care doctors for not owning their share of the problem, but it’s just not that simple,” Waller said. “We’ve set them up for failure.”
Until the 2000 passage of the Drug Abuse Treatment Act, the American medical system largely treated those with substance abuse disorders by encouraging abstinence and directing patients to treatment centers, mental health counselors, or 12-step programs like Narcotics Anonymous. Some medical schools — particularly those in urban settings — train students on addiction management, but many only offer cursory guidance on such issues.
Among other measures, the legislation made it possible for more clinicians to treat patients with buprenorphine, one of the few opioid addiction treatments approved by the Food and Drug Administration.
Buprenorphine, most commonly known by the brand name Suboxone, is an opium derivative that produces a normalizing effect on the brains of people who are addicted to opioids. In proper doses, the treatment allows patients to carry out their normal daily activities, while blunting cravings for opioids. It also can block the effects of drugs like heroin and methadone.
But buprenorphine is just one part of addiction management.
The eight-hour certification course currently offered to clinicians seeking to treat opioid use disorders includes four hours of online training and four hours of live instruction. That, experts say, is not enough time to give primary doctors any semblance of confidence that they can manage the psychosocial complexities of patients with opioid use disorders.
In addition to writing a prescription for buprenorphine, for instance, doctors must understand how to approach patients who commonly suffer from cognitive impairments and mental health pathologies that often have their roots in early-life trauma. Doctors who coordinate treatment with mental health providers must also navigate at times thorny privacy issues, and brace for the possibility that patients will sell buprenorphine prescriptions on the black market.
To face such complexities after a mere eight hours of training, Waller said, “it can be pretty scary for someone in primary care.”
For these reasons and others, physicians groups have supported the training programs around medication-assisted treatment for opioid use disorders, but only to a point.
The largest physician group, the American Medical Association, backs increased training for the medication-assisted treatment of opioid use disorders among its members, but it opposes mandatory training.
The AMA believes that such training may not be relevant to all primary care physicians. Some doctors do not prescribe opioids, for instance, while medical practices might lose money on such treatments because of inconsistent insurance coverage of opioid addiction medications.
Dr. John Meigs, president of the American Academy of Family Physicians, said opioid abuse “is so rampant, and we’re the specialty with the broad training in comprehensive, whole-person care, that it is appropriate for us to help take care of this need.”
But Meigs himself, who has practiced medicine in rural Alabama for 34 years, said he “has not had time” to become certified, and that he does not know how long the process takes. It is, however, something he intends to do in the future, he said.
Of all the primary care doctors to have made the transition to treating opioid-addicted patients, Dr. Leslie Hayes is perhaps the most highly recognized.
Earlier this year, Hayes won recognition from the White House as a “champion of change,” for her role in addressing the opioid-overdose crisis.
Her territory: Española, New Mexico.
When she started practicing here roughly 25 years ago, Hayes said she “didn’t realize there was actually stuff you could do, and how much you could do. So I did the best I could.”
That meant she practiced the standard approach to those with addiction disorders.
“The default was to say ‘You need to quit drinking and using drugs,’” she said. “Then refer them to NA. It’s a great option for some, but it doesn’t work for everybody.”
In 2003, Hayes heard about a new program in New Mexico, Project Echo, which trained primary care clinicians remotely in various medical specialties. She worked under the guidance of Dr. Miriam Komoromy, a professor at the University of New Mexico School of Medicine, and by the following year was trained to treat patients with substance abuse disorders and certified to prescribe buprenorphine.
“Leslie is my hero,” said Komaromy. Even though Hayes carries no board certifications in addiction management or OB/GYN medicine, Komaromy said, “she’s one of the state’s recognized experts in opioid addiction in pregnancy.”
Hayes is quick to point out that buprenorphine is not a cure-all. Some of her patients have learned that the hard way.
Bobby Delgado, 45, saw Hayes, who helped him get Suboxone for free because he couldn’t afford the $10 per-pill copay. Within three years, Delgado relapsed.
“Suboxone does work, but you have to do your share of the legwork,” he said. “Going to meetings, going to your appointments. All of this is a factor.”
Of all the skills Hayes learned during training, she said the most valuable has been what is known in psychology circles as “motivational interviewing.”
“If you tell someone the reasons they need to stop, they’ll go the opposite way,” she said. “So the idea is to get the patients to voice the reasons they want to quit, so if they voice that, they’re much more likely to follow through with them.”
Hayes said she will ask patients to rate, on a scale of 1 to 10, the importance of quitting drugs, and then rate their confidence in their ability to do so.
“And I always ask what good things they get out of using. If you can figure out what those things are, and if they can figure out another way to achieve that, it can be very helpful.”
Hayes said she sometimes remembers patients she saw before she received advanced training in the treatment of addiction. Among them was a young woman who was repeatedly turned away from busy rehab centers, until she was later convicted on drug charges and ordered by a judge to admit herself to inpatient care.
Years later, Hayes saw her in the local hospital.
“She’d aged so much — her memory was shot, and she was clearly still using and not doing well at all. She didn’t remember who I was, which made me kind of sad,” Hayes said.
If Hayes had been certified to treat the woman with buprenorphine during her early visits, she said, she likes to believe the woman’s outcome would have been different.
“I can’t say for sure, of course,” she said. “But she’d have had a much better shot.”