Primary care physicians reluctant to prescribe opioid-use disorder medications

A recent survey in the “Annals of Internal Medicine” finds nearly one-third of primary care physicians (PCPs) reluctant to prescribe opioid-use disorder (OUD) medications, described as the “gold standard” for safe, effective treatment.

“Medication for Opioids Use Disorder: A National Survey of Primary Care Physicians” sampled 1,000 family, internal and general medicine PCPs from the American Medical Association Physician Masterfile to report low interest and support for treating OUD patients and prescribing methadone in office-based settings. Unilateral policy changes won’t lead to widespread use of primary care-based OUD medication treatment, states the survey from Johns Hopkins Bloomberg School of Public Health, Baltimore.

“Treating patients, long term, for OUD is time and resource intensive. These patients are often seen as undesirable for many reasons, not the least of which, is the tendency to relapse, the monitoring required and perceived risk to the provider if they (physicians) misdiagnose or the patient overdoses, explains Halena M. Gazelka, MD, associate professor, anesthesiology and perioperative medicine, Mayo Clinic, Rochester, Minn.

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Indeed, Alan I. Schwartzstein, MD, FAAFP-family physician, SSM Health Dean Medical Group, Madison, Wis.-says “Many physicians have had the experience of people coming to their office with OUD who focus, specifically, on medications they’re trying to get. It’s the same as alcohol-use disorder. That sets up a challenging communication between doctor and patient,” explains Schwartzstein who serves as speaker for the American Academy of Family Physicians Congress of Delegates, Leawood, Kan.

The survey found perceived effectiveness of OUD treatments varied with almost 78 percent endorsing buprenorphine, more than 62 percent methadone and almost 52 percent injectable, extended-release naltrexone. Almost 12 percent support waivers to prescribe buprenorphine with lesser support for injectable naltrexone waivers, it states.

“The best evidence for medication-assisted therapy (MAT) in OUD is buprenorphine compounds. I suspect that reflects not only the understanding of OUD management, but the amount of press and studies published in recent years,” speculates Gazelka.

Adds Schwartzstein: “It’s impressive that the majority felt these (medications) were effective and important. Where it dropped off were people who have yet to try it and need to incorporate MAT into their practices,” suggests Schwartzstein who supports eliminating prior authorizations, required by insurance companies to reimburse prescribed MAT.

“If a person uses their opioid of choice and wants to get off of it, going through the prior authorizations to get this is a challenge. They throw a cold shower on physicians who might want to adopt this practice,” he notes.

Likewise, Gazelka thinks the rules, imposed on prescribers, by the U.S. Drug Enforcement Administration, Arlington, Va., and lack of available therapies hinder MAT. “Good addiction medicine treatment is not limited to providing MAT. Patients require psychosocial support, counseling by behavioral specialists well-versed in addiction and its therapy.

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“Many patients, suffering from addiction, suffer from concurrent psychiatric illness, which complicates their management, significantly, for a provider not trained in addiction medicine or psychiatry,” she says.

According to the survey, most physicians endorse insurance coverage (81.8 percent) and government investment in OUD medications (76.4 percent). Long-term solutions include incorporating addiction medicine into physician training and primary-care practice, it asserts.

Schwartzstein supports adding an addiction medication specialist to practices, but notes “Even if we increase the number of people who specialize in addiction medication, there won’t be enough to manage people with this disorder. It will require a family physician with a waiver to prescribe.”

Gazelka adds, “In residency, PCPs need to not only understand, but be able to initiate treatment for OUD. Many primary care residencies incorporate training in buprenorphine prescribing and the ability to earn a waiver, into their programs.”

Schwartzstein sees the results. “A lot of physicians in residency are learning to treat OUD. As they come in, you don’t have the experience others of us had with the negative interaction. I think that’s great,” he says.