The Big Debate in Addiction Treatment: Should Primary Care Physicians Treat Opioid Addiction?

The Big Debate in Addiction Treatment: Should Primary Care Physicians Treat Opioid Addiction?

There's a heated discussion going on among the country's primary care physicians, addiction specialists and everyone else involved in addiction treatment and funding. A recent article in STATNews raises the question that's getting so much discussion: Should primary care doctors be involved in treating opioid addiction? From the White House and Congress all the way down to the nurses and even the receptionist in your local clinic, everyone has an opinion one way or the other. And the answers are as interesting as they are often polar opposites. Sometimes you will hear this: "Yes we should. These are sick people who need medical care." Maybe not too surprisingly, even this: " No, we don't want those people in our waiting room." But mostly you will hear this, over and over again: "We have no training in addiction treatment. And how will we be reimbursed for our time? It's simply not our job." In fact, most primary care doctors encountering an addicted patient "follow an old script," says STATNews. They simply "refer patients to addiction centers and Narcotics Anonymous, and move on."

Could family physicians really make a difference?

Every year in America, something like 20,000 people die from opioid-related poisonings. Would many of these people, or even some of them, still be alive if family doctors were able (and willing) to offer opioid addiction treatment? The simplest and most obvious would be with buprenorphine, most commonly known by the brand name Suboxone. Buprenorphine curbs opioid cravings in most opioid-dependent patients. Doctors can inject buprenorphine in the office, while some patients can take a supply home for a week or more. It's like methadone dispensed from methadone clinics, which is itself controversial. However, unlike methadone, buprenorphine is a "partial opioid agonist" which means it satisfies some of the craving for opioids but doesn't get you high. That means buprenorphine can help an addict deal with physical dependence on opioids like heroin - and methadone - without itself being a serious drug of abuse.

What exactly does buprenorphine do?

According to the National Alliance of Advocates for Buprenorphine Treatment (NAABT), at low doses "buprenorphine produces sufficient agonist effect to enable opioid-addicted individuals to discontinue the misuse of opioids without experiencing withdrawal symptoms." The NAABT says that buprenorphine offers:

  • Less euphoria and physical dependence
  • A lower potential for misuse
  • A ceiling on opioid effects
  • A relatively mild withdrawal profile.
At the appropriate dose buprenorphine treatment may:
  • Suppress symptoms of opioid withdrawal
  • Decrease cravings for opioids
  • Reduce illicit opioid use
  • Block the effects of other opioids
  • Help patients stay in treatment.
This all sounds wonderfully attractive. What a great idea. And last year the government vastly expanded its buprenorphine certification program for family physicians. So why aren't doctors lining up for the training? So far, only one percent of the country's roughly 210,000 primary care physicians have taken advantage of the training. Michael Botticelli, the director of the White House office of national drug control policy, is himself a primary promoter of buprenorphine use by family doctors. During a recent forum in Albuquerque, NM, on the opioid crisis, Botticelli said the absence of a stronger response from physicians was "deplorable." Why doctors have failed to respond in droves will become painfully obvious, once you get the buprenorphine stars out of your eyes. Buprenorphine is not "addiction treatment" Obviously, the main answer to "the big question" about family doctors treating opioid dependence with buprenorphine is contained in that last point in the list above:
  • "Helps patients stay in treatment."
Injecting buprenorphine and calling it "addiction treatment" is way too simplistic, really way off the beam. It helps people "stay in treatment." Quite certainly, a simple injection of buprenorphine is not treatment. It's partial treatment. Reducing the craving for opioids is at best just the start of what can be called real addiction treatment. So what then is treatment? Buprenorphine can be an effective component of treatment, especially when used short term in a medical detoxification program. For example, buprenorphine is used here at Novus to treat patients trapped on long-term methadone programs, resulting in high daily doses of methadone. This is a frequent result of failures of such programs to provide all the components of addiction treatment. Real addiction treatment includes weeks or months of effective rehabilitation after detoxification, long after buprenorphine or any other psychoactive drug is needed to control cravings and withdrawal symptoms.

Not enough training and few incentives for physicians

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. According to StatNews , experts say that "isn't enough time to give primary doctors any semblance of confidence that they can manage the psychosocial complexities of patients with opioid use disorders." Dr. R. Corey Waller, an addiction-treatment specialist who leads the advocacy division of the American Society of Addiction Medicine (ASAM) told STATNews recently that there are few incentives for primary care doctors to get trained. And that's especially true in the many states whose Medicaid systems do not reimburse physicians for addiction treatment. Writing a prescription for buprenorphine must include "a broad understanding of how to approach patients who commonly suffer from cognitive impairments and mental health pathologies that often have their roots in early-life trauma." Without such training, family doctors are just not equipped. To face such complexities after a mere eight hours of training, Waller said, "it can be pretty scary for someone in primary care." "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 added. "We've set them up for failure." At Novus, we favor the use of some substances - buprenorphine, for example, and especially nutritional assistance - to speed a comfortable and effective opioid detoxification. But it's also been our experience that a long-term, drug-free rehabilitation is the best way to achieve a drug-free life. A lifelong dependence on buprenorphine or methadone is hardly "addiction treatment."

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