A recurring theme I and many other addiction researchers and professionals keep reiterating is the treatment gap: the underutilization of effective treatments that could make a serious dent in the opioid crisis and overdose epidemic. Ample evidence shows that when used according to guidelines, the agonist medications methadone and buprenorphine reduce overdose deaths, prevent the spread of diseases like HIV, and enable people to take back their lives. Evidence supporting the effectiveness of extended-release naltrexone is also growing; but whereas naltrexone, an opioid antagonist, can be prescribed by any provider, there are restrictions on who can prescribe methadone and buprenorphine.
A series of editorials in the July 5, 2018 issue of the New England Journal of Medicinemade a strong case for lessening these restrictions on opioid agonists and thereby widening access to treatment with these medications. For historical reasons, methadone can only be obtained in licensed opioid treatment programs (OTPs), but as Jeffrey H. Samet, Michael Botticelli, and Monica Bhareldescribe, experimental U.S. programs delivering it through primary care have been quite successful, as have other countries’ experiences doing the same thing.
Although buprenorphine can be prescribed by primary care physicians, they must first take eight hours of training and obtain a DEA waiver, and are then only allowed to treat a limited number of patients. As Sarah E. Wakeman and Michael L. Barnettargue, these restrictions are out of proportion to the real risks of buprenorphine and should be lessened so more people can benefit from this medication.
Stigma also contributes to the resistance to using evidence-supported treatment—both stigma against addicted individuals and stigma against agonist medications, due to the persistent myth that they just substitute a new addiction for an old. This idea reflects a mistaken conflation of dependence and addiction. Dependence is the body’s normal adaptive response to long-term exposure to a drug. Although people on maintenance treatment are dependent on their medication, so are patients with other chronic illnesses being managed medically, from diabetes to depression to pain to asthma.
Addiction, in contrast, involves additional brain changes contributing to the loss of control that causes people to lose their most valued relationships and accomplishments. Opioid-dependent individuals do not get high on therapeutic doses of methadone or buprenorphine, but they are enabled to function without experiencing debilitating withdrawal symptoms and cravings while the imbalances in their brain circuits gradually normalize.
Unfortunately, it is not only bureaucratic restrictions and attitudinal impediments that prevent healthcare providers from making wider use of medications. As one Oregon addiction medicine specialist, Jessica Gregg, wrote in a July Huffington Posteditorial, there is also an understandable reluctance by some physicians to throw more medications at a problem that is widely understood to have been initiated by over-aggressive prescribing for all kinds of pain. What is more, many or most physicians simply don’t feel capable of treating these complex patients; their medical school training likely didn’t equip them to handle patients with substance use disorders, just as it did not equip them to manage complex and chronic pain effectively and safely.
Treating patients with addiction may be uniquely complex and demanding for several reasons. Patients may have comorbid medical conditions, including mental illnesses; thus, they may need more time than doctors are reimbursed for by insurers. They may also have pain, and while pain management guidelines have changed to respond to the opioid crisis, those changes have not necessarily made physicians’ jobs any easier, since there are currently no alternative medications to treat severe pain that are devoid of dangerous side effects.
Because of the complexity of opioid use disorder (OUD), providers may find that it is not sufficient to simply dispense a new prescription after a quick consultation. These patients often need ancillary services provided by nurses or other treatment specialists; and in the absence of these extra layers of support, treatment is less likely to be successful, reinforcing physicians’ reluctance to treat these patients at all.
In short, physicians are being blamed for causing the opioid epidemic, but thus far they have not been aided in becoming part of the solution.
Medical schools are starting to respond to the opioid crisis by increasing their training in both addiction and pain. For example, as part of its training in adolescent medicine, the University of Massachusetts Medical Schoolhas begun providing pediatric residents with the eight-hour training required to obtain a buprenorphine waiver—an idea that is winning increasingly wide support. The Warren Alpert Medical Schoolof Brown University was the first to implement such a program for its fourth-year medical students.
Physicians in some emergency departments are also initiating overdose survivors on buprenorphine instead of just referring them to treatment. And through its NIDAMED portal, NIDA provides access to science-based information and resources on OUD and pain to enable physicians to better address these conditions and their interactions, including easy-to-use screening tools to help physicians identify substance misuse or those at risk.
But if physicians are going to assume a bigger role in solving the opioid crisis, healthcare systems must also support them in delivering the kind of care and attention that patients need. Physicians need the tools to treat addiction effectively as well as the added resources (and time) for patients who need more than just a quick consultation and a prescription.