Every community in America has been touched by the opioid crisis. With so many individuals impaired by addiction, primary care physicians have significant opportunities to better serve their patients with appropriate treatment.
Medication assisted treatment (MAT) is an evidence-based modality to consider adding to your medical practice. Science supports the use of medications for addiction, and prescribing physicians have found the experience of helping such patients rewarding, even if they haven’t treated addiction in the past.
Addiction in context
More than 11 million people misused opioids in 2017, according to the Substance Abuse and Mental Health Services Administration (SAMHSA), with highest use among those ages 18 to 35. Additionally, there were more than 47,000 opioid-overdose deaths in the United States in 2017, according to the Centers for Disease Control and Prevention.
Yet, treatment access remains abysmal. Only about 12 percent of those with substance use disorder (SUD) receive treatment. The reasons for low utilization vary, but many center on the difficulty for patients to find or afford SUD treatment.
“We have a flood of people who are using opioids and are in trouble,” says Paul Earley, MD, DFASAM, president of the American Society of Addiction Medicine (ASAM). “As an addiction medicine provider, I can’t keep up with the demand. There is definitely a need to get more providers out there prescribing MAT.”
According to SAMHSA data, roughly 2 million people with opioid addiction who would benefit from MAT aren’t receiving it.
Researchers at Rand Corporation have also warned that there aren’t enough specialty providers to meet the demand for even a 50 percent increase in the number of people seeking treatment for addiction. Therefore, primary care should be mobilized as an access point. The shift is similar to previous care-delivery changes that increased treatment of depression in primary care settings.
Getting started with MAT
The FDA has approved three medications to treat opioid addiction: methadone, buprenorphine and naltrexone. While methadone can only be dispensed in federally regulated clinics, buprenorphine and naltrexone can be prescribed and dispensed in an office setting.
How can practices begin the process of adding MAT? It usually starts with training.
To prescribe buprenorphine, regulations require physicians to complete eight hours of training and obtain a Drug Enforcement Agency waiver. With additional training, nurse practitioners and physician assistants can also qualify.
Approved training is available online or in-person — often at no charge — through a number of resources, including SAMHSA. To date, SAMHSA reports there are 64,000 waivered buprenorphine prescribers in the United States, but more are needed.
For naltrexone, which isn’t a narcotic, there are fewer regulations, and prescribers aren’t required to obtain a waiver. However, experts caution that naltrexone can cause serious side effects for those still using opioids. Most patients will need to be opioid-free for about 10 days before starting the treatment. It also tends to be the costliest MAT drug.
At CHI St. Gabriel's Family Medical Center in Little Falls, Minn., two family physicians decided to start prescribing buprenorphine after seeing a significant unmet need for care among their patients. Heather Bell, MD, and Kurt Devine, MD, currently treat about 90 patients with the medication.
“A lot of people in medicine believe MAT is just substituting one drug for another drug, and we once had that same mind-set,” Bell says. “In understanding opioid use disorder, you understand how it changes the brain, and it’s really not possible for patients to just ‘be abstinent.’”
The mind-set is the greatest challenge to overcome for prescribers, she says. Unfortunately, it’s a common perception that reflects the larger stigma around addiction, treatment and recovery. “Once you start prescribing buprenorphine, you see how much better the patients’ lives become,” Earley says. “Then you see it’s not substituting one drug for another. It’s a treatment protocol.”
Often, addiction issues are addressed only when people are at their worst, he says. That creates the perception that everyone with addiction is always at rock bottom.
But that’s not always the case. Many patients are open to treatment well before they’ve reached crisis status, which offers physicians and providers opportunities to intervene.
MAT can allow those with opioid addiction to get past the cravings and distractions of drug-seeking behavior and focus on recovery. Patients report finally feeling “normal” when they take buprenorphine, Bell says, and it doesn’t produce euphoria, even at high doses.