How to help your patients with opioid addiction

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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.

Changing mind-set

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.

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
  https://www.samhsa.gov/providers-clinical-support-system-medication-assisted-treatmenthttps://learning.pcssnow.org/p/onlinematwaiver
   

• Join a mentoring group, such as Project ECHO, or through ASAM’s Fundamentals Course
  https://www.chistgabriels.com/echo/www.ASAM.org/fundamentals
   

• 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.