Help from fellow doctors
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 Project ECHO (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 Fundamentals course, a 40-hour on-demand CME experience that covers how to recognize, screen, treat and refer patients with addiction.
Momentum for MAT
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.
Medications for opioid use disorder
- Methadone—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.
- Buprenorphine—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.
- Naltrexone—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.
- Naloxone—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.
How to ramp up MAT at your practice
- Complete the 8-hour training and obtain a waiver from the Drug Enforcement Agency
- 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.