Julie Miller

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. 

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.

 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 

 in the United States in 2017, according to the Centers for Disease Control and Prevention.

Yet, treatment access remains abysmal. Only about 

 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 

 (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.”

 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 

 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.

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 

. 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.

 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.

The St. Gabriel’s physicians see two or three buprenorphine patients per day. While some primary care practices might anticipate more intensity in the office visits, MAT patients typically are no more challenging than those who need to manage other chronic conditions, such as diabetes or heart disease, Bell says.

But learning from the experiences of other prescribers can be instrumental in improving care. “A big barrier for us was that we had no mentors to help us get started,” Devine says. “Suboxone (buprenorphine) was being prescribed in metro areas by addiction physicians, so we searched out those physicians to help.”

The peer collaboration allowed them to learn through others’ clinical experiences. Now, Bell and Devine advise fellow physicians through 

 (Extension for Community Healthcare Outcomes), a national group that’s open to anyone. They’ve also mentored 40 primary care providers who offer MAT services to about 150 patients, Bell says.

Clinical protocol recommends that MAT patients also be referred to specialty behavioral health therapy within the community. Bell says some of her patients coordinate with a social worker, some need outpatient care, and others are referred to more intensive services, depending on their needs.

However, she doesn’t see therapy as a deal-breaker for patients to receive MAT. She just wants them to begin buprenorphine and stop their substance use as soon as possible. With the risk of overdose reduced, they can start working toward long-term recovery.

Earley says primary care physicians and other providers should consider making referrals to specialized treatment for certain patients, such as those with polysubstance use, those with comorbid psychiatric conditions and those with chronic pain.

“You build your multidisciplinary team, and you stay connected,” Earley says, adding that the team approach with a network of referents also provides greater satisfaction for the prescribing physicians.

Additional education and peer support is available through ASAM’s 

 course, a 40-hour on-demand CME experience that covers how to recognize, screen, treat and refer patients with addiction.

A number of tailwinds are helping to advance the use of MAT in primary care practices. For example, many commercial insurers have recently eliminated prior authorization requirements for the medications. Federal legislation has also relaxed some of the limits around prescribing, and health agencies have increased grant funding to support best practice research.

Finally, there is increasing demand for medication as a pathway to recovery from addiction, and more providers are challenging their biases about MAT services.

“Until primary care jumps on board and embraces this as a way to help people, reversing the opioid epidemic is not going to happen quickly,” Bell says.

Julie Miller is a freelance writer based in Cleveland.

-Full opioid agonist that is only dispensed in federally regulated clinics. It reduces withdrawal symptoms and cravings. The typical delivery mechanism is oral liquid or tablets. Can be used in early stages of withdrawal.

-Partial opioid agonist that can be managed in an office setting by qualified clinicians. It reduces withdrawal symptoms and cravings. Manufacturers typically combine it with naloxone so it does not produce euphoria, even at high doses. The most common delivery mechanism is sublingual film, but tablets, subcutaneous implants and long-acting injections are also used. Can be used in early stages of withdrawal.

-Opioid antagonist that can be managed in an office setting. It reduces cravings but cannot be used in withdrawal. It is not a narcotic and does not cause dependence. The most common delivery mechanism is a long-acting injection, but tablets are also available.

-As a stand-alone medication, it is used by first responders and bystanders to reverse the effects of opioid overdose. Injectable and nasal spray forms are available. It initiates withdrawal, so it is not used for ongoing treatment of addiction but rather as an acute rescue medication for overdose. In many states, naloxone is available without a prescription.

Complete the 8-hour training and obtain a waiver from the Drug Enforcement Agency
		

https://www.samhsa.gov/providers-clinical-support-system-medication-assisted-treatment

https://learning.pcssnow.org/p/onlinematwaiver

Join a mentoring group, such as Project ECHO, or through ASAM’s Fundamentals Course
		

Reinforce the evidence behind the use of MAT to change the mindset among your clinical and practice staff as well as your patients.
		 

Develop resources to refer MAT patients to behavioral health therapy to support recovery.

Articles

Primary care physicians can help fight the opioid epidemic by offering medication assisted treatment.

How to help your patients with opioid addiction

Trends indicate that clinicians are identifying autism spectrum disorder (ASD) 

 than ever before. According to the Centers for Disease Control and Prevention, about 

 published in December 2018 estimates the number is 

 to track ASD trends among adults. Experts agree that the delivery system is fairly well established for children, but few best practices exist for treating adults with ASD.

It also stands to reason that the children diagnosed in the 1980s and 1990s when rates began to surge have now become adults who represent a population with unique medical and behavioral health needs. These adults face many barriers to care, including fear and anxiety related to doctor appointments, coupled with inadequate support from medical professionals.

Today’s community providers have little training on ASD and are ill-equipped to take care of adult patients on the autism spectrum, says Christina Nicolaidis, MD, MPH, a researcher and professor at 

 who also practices internal medicine at 

“I’m hopeful that we’re making progress, but we have such a long way to go,” she says.

Here are four changes practices can make immediately to better care for adults with ASD.

Adults on the spectrum are a heterogeneous group, and each patient will have different abilities and highly individualized needs. In fact, some of Nicolaidis’ research found that healthcare providers make incorrect assumptions about patient abilities. Therefore, personal information is essential to establish the patient-provider relationship.

As the co-founder and co-director of the 

Academic Autism Spectrum Partnership in Research and Education (AASPIRE),

 Nicolaidis helped design the partnership’s 

Autism Healthcare Accommodations Tool (AHAT). 

The free online tool walks patients through a series of questions to identify what type of accommodations would help make physician visits easier for them. Responses are then used to generate a customized PDF that patients can use as a communication tool to express their specific needs. The document might include suggestions for office staff about helping patients schedule appointments when they are unable to use a telephone, for example.

“There might be thousands of different things you could do, but for a particular patient, you might only need a few of them to improve the healthcare experience,” Nicolaidis says.

AHAT research demonstrates high satisfaction with 90 percent of patients saying they would recommend the tool to others, and more than 600 people have used the tool so far, she says. The PDF can also help physicians feel more comfortable in seeing patients with ASD.

Individuals on the spectrum experience difficulty accessing services for routine medical treatment for a number of reasons, including the fact that there simply aren’t enough physicians prepared to accommodate those with ASD, says Zoe Gross, director of operations for the 

, a Washington, D.C.-based not-for-profit.

“A lot of people with developmental disabilities see pediatricians into adulthood-as a general practitioner or a specialist-because they have a hard time finding a general practitioner,” Gross says.

Reduced access can translate to poorer quality of life and even early death. Gross cites a 

 that shows the risk of premature death is about 2.5 times higher for people with ASD than for the rest of the population in almost all cause-of-death categories.

Providers should be aware that those on the spectrum tend to have medical conditions that correlate to stress, such as sleep issues, anxiety, or depression. As a population, they are more likely to have -connective tissue diseases and epilepsy as well, she says.

ASD is often characterized by atypical speech and communication, making it more challenging for people on the spectrum to interact with care providers. Gross says two recurring issues contribute to barriers in the care delivery process.

First, clinicians outside the behavioral health specialty typically don’t have any practical training on how adults with ASD might communicate. For example, a patient often will need additional time to formulate verbal responses to questions. In some cases, a patient who is nonverbal will communicate by typing on a device, such as a tablet.

About one-third of children with ASD are minimally verbal, meaning they use only a small number of words or phrases, according to a spokesperson for 

, a national advocacy group. Verbal challenges can persist into adulthood.

However, clinicians might smooth out the interaction by waiting patiently for verbal or typed responses. Consider offering multiple choice answers for questions or examples of what other people might say in reply to a particular question. It’s often helpful to speak in concrete terms and avoid figurative language, according to experts.

, published in the September 2016 issue of 

 reveals that in a survey of 209 adults with ASD, 32 percent say they can’t process information fast enough to have a real-time discussion about healthcare. Patients simply need more time.

Read more: How to improve interactions with special needs patients

The second common barrier, according to Gross, is that clinicians sometimes default to stereotypes when communicating with adults with ASD. For example, a well-intentioned provider might share protected health information with the patient’s family without securing a HIPAA release first-as if the patient were a child and not an adult.

“The doctor might have been told that patients with autism need guardianship, which is not true,” Gross says. “They might have been told people with autism often get support and have generalized that to think they don’t need the person’s permission to speak to someone else about their health.”

She recommends clinicians communicate with the patient directly, even when a support person is present in the room. Don’t assume the other person is there to manage the patient’s health.

Also, she says, “make sure the patient is going home with treatment plans they’re able to follow.” Written instructions are often helpful.

Gross says pain symptoms are especially tricky to manage because patients might have atypical pain perception that doesn’t fit within common medical vocabulary. With this challenge, physicians can inadvertently miss a diagnosis that hinges on pain sensations.

“I’ve heard of people experiencing issues up to and including broken bones that were not detected by doctors because of situations like that,” Gross says.

 developed by AASPIRE. The tool allows the patient to communicate concerns in detail by writing out short answers to questions, such as, “When did you first notice the symptom?” A visual pain scale and body diagram also allows the patient to indicate issues by marking pictures with circles or X’s. The worksheet can be prepared ahead of time and shared with the physician.

For those on the spectrum, one or more of the senses can be 

. Oversensitivity in particular can compromise the patient’s ability to tolerate a healthcare encounter, and 30 percent of adults with ASD in the 

 report say healthcare facilities cause them sensory discomfort.

Physicians can help by reducing noise, light, and distractions as much as possible during the visit, Nicolaidis says. For example, silence equipment with audible beeping sounds and turn off room lights when window light is available.

Remember that touch can be difficult for some patients to tolerate, so clinicians should explain what they’re going to do before making any physical contact. Even a light touch can be overstimulating.

When a procedure is needed, Nicolaidis recommends physicians offer patients the opportunity to experience a trial run first. During the trial run, talk about the steps during the process and show the patient what he or she might hear, see, or feel. Also allow the patient to schedule the trial run and procedure on separate days to allow time in between to prepare for the experience.

Nicolaidis says she used the trial run approach to help one patient on the spectrum become comfortable with a pelvic exam. Previously, the patient had required general anesthesia.

The healthcare infrastructure is complex for any patient to manage, but it’s especially difficult for those with ASD. Spending time in a waiting room can lead to anxiety and can discourage interaction.

 report, 21 percent say they find it difficult to wait in the waiting room, and 18 percent say the wait is too long.

“If you tend to run late, it might bother all your patients, but it can be particularly problematic for a patient on the spectrum,” Nicolaidis says. “By the time you’re seeing them, it’s possible the stress level has become so great, they can’t communicate clearly.”

More than 20 percent of survey respondents also say doctor appointments are too short to accommodate their communication needs.

Nicolaidis recommends scheduling appointments first thing in the morning to avoid idle time in the waiting room and reduce distractions, such as other patients coming and going. Alternatively, the last appointment of the day can offer an open-ended visit in which the physician can allow plenty of extra time without the pressure to scurry off to the next patient. For a midday visit, consider blocking off two appointment slots to reduce the rush.

Gross recommends that in addition to allowing for more time, providers should think creatively and be prepared to “really listen.”

As the diagnosis rate of autism spectrum disorder rises, physicians increasingly need to accommodate a population with special considerations.

Author | Julie Miller

Articles

How to help your patients with opioid addiction

Make your practice friendlier for adults on the autism spectrum