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Frontline caregivers need the most appropriate tools, though access is a challenge.
As the opioid crisis continues, frontline caregivers need the most appropriate tools to combat the opioid crisis, including medication-assisted treatment (MAT).
But do they have access to them? And are there enough of these frontline caregivers with the tools they need to help people suffering from an opioid addiction?
Access is a challenge
Medication-assisted treatment, or MAT, involves the use of certain medications, along with counseling and other behavioral therapies. Buprenorphine is one of the three FDA-approved medications used in MAT, according to the Substance Abuse and Mental Health Services Administration (SAMHSA).
Currently, access to this kind of treatment is a challenge for patients across the country, says Mohammad Zare, MD, associate professor and vice chair of community services in the Department of Family and Community Medicine at McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth) and the chief of staff of Ambulatory Care Services in the Harris Health System.
In Houston, the methadone clinics can’t handle the volume of patients affected with an opioid use disorder.
Improving access to treatment and recovery services and promoting the use of overdose-reversing drugs are two of the U.S. Department of Health and Human Services’ five top priorities in responding to the ongoing opioid crisis, but clinicians can’t just prescribe Buprenorphine when they want to; physicians must obtain a special waiver certifying that they’ve completed relevant training.
The federal Drug Addiction Treatment Act of 2000 (DATA 2000) requires that healthcare practitioners apply for a waiver in order to prescribe or dispense buprenorphine as a treatment for an opioid use disorder. First, physicians convey their intent to apply for a waiver to the SAMHSA Center for Substance Abuse Treatment (CSAT). Currently, physician applicants must provide proof they’ve completed an eight-hour training course, plus their DEA number and their state medical license number, to be eligible to apply for a first-time waiver.
Zare is the co-site principle investigator of a site in Houston that’s part of the national Primary care Opioid Disorders (PROUD) study, a clinical trial designed to examine which strategies can increase buprenorphine prescription rates in primary care settings.
Zare’s team is testing out a collaborative care approach called the Massachusetts Model. They’re comparing one clinic with a clinical nurse manager to support three waiver-trained primary care providers against a control clinic without that additional support. They hope to find out if that support can expand the number of patients they’re able to see and treat in a primary-care setting.
The goal is to find an approach that reaches more people who need MAT so they can experience long-term success. “They become more functional. They go back to work against. They start having a job and going back to their families,” says Zare.
Continue reading on page 2...Is the waiver requirement a barrier?
Some suggest that the waiver requirement is a barrier to having more frontline clinicians prepared to provide MAT. But how much of a barrier is this requirement to get a waiver?
The waiver does set limits to the number of patients to whom a provider can prescribe buprenorphine, but the training course is free and providers can complete it at their leisure, notes psychiatrist Michael Mancino, MD, program director of The Psychiatric Research Institute’s Center for Addiction Services and Treatment (CAST) at the University of Arkansas for Medical Sciences (UAMS).
“That is not a significant barrier,” he says.
Nurse practitioners, PAs, and other advanced practice nurses can get waivers, too. They must complete 24 hours of training, or they can also take the same free eight-hour training that physicians take, plus an additional 16 hours of training from SAMHSA.
In Arkansas, the number of providers with waivers has grown from 85 to more than 300 over the past few years, according to Mancino. But he says the waiver isn’t the biggest hurdle standing in the way of people gaining access to more waiver-trained clinicians.
“The number one barrier in Arkansas is stigma,” says Mancino.
He explained that some clinicians don’t believe that addiction is an illness, thought it should be treated as such. Instead, some still view addiction to opioids (or other substances) as a moral failure or lack of willpower.
Zare agrees that the mindset needs to shift. “Substance use disorder is a chronic disease,” he says. “We don’t stigmatize someone who has hypertension, we manage it chronically. We need to take patients with substance use disorder and treat them the same way.”
What else is needed?
A recent study in the journal Drug and Alcohol Dependence examined the disparity between opioid overdose deaths and available treatment services in Flint, MI. The researchers found that opioid treatment centers were rarely located in the areas where the most overdose deaths occurred.
That’s critical information because it shows where the greatest need lies and illustrates a geographical barrier for people who may want to access treatment but can’t, according to researcher and epidemiologist Deborah Furr-Holden, PhD, associate dean for public health integration at Michigan State University and director of the Flint Center for Health Equity Solutions.
The study also illustrates the need for more healthcare professionals who are specialists in in addiction medicine, says Furr-Holden. A generalist with waiver training can be helpful, but having an adequate number of experts with the specialized training and experience is really critical.
“Do you want an orthopedist delivering your baby?” Furr-Holden says. “You want somebody who’s trained. Treating addiction isn’t something that we can just make up as we go along.”
“Our training and medical education needs to catch up to the problem,” she says.