Stopping prescription drug abuse starts with primary care

Stopping prescription drug abuse starts with primary care

As with any disease, prevalence of this narcotics abuse is region-specific; an hour north of the office where I practice, Rio Arriba County in New Mexico is home to one of the highest opioid overdose rates in America – up to five times higher than the national average.  Our patients routinely lose family to addictions; our clinic has been home to a near-fatal overdose within the walls of the facility.

Addictions treatment has always orbited the periphery of mainstream medicine, and the recovery community has traditionally been averse to medical intervention for what was historically considered a condition of weak will, most amenable to talk therapy and group support.  With the advent of supported sobriety medications like buprenorphine for opioid dependence and naltrexone for alcohol cravings, addictions treatment has shifted  sharply toward a medicalized model.  But with an estimated 23 million Americans needing help with addictions (2 million of those dependent on opioids alone) and a few thousand addiction specialists across a number of specialties (the exact number is difficult to estimate, as the American Board of Medical Specialties does not recognize an addictions medicine specialty outside of psychiatry), the numbers simply do not add up: too many patients, too few specialists.  The result is that patients are simply not offered straightforward, life-saving medicine.  An appropriate analogy is a situation in which all diabetics are denied treatment unless they locate themselves an amenable endocrinologist.

The only specialty with a front-lines army legion enough to provide for this population is primary care.  But primary care has been remiss in stepping up to its responsibility for this routine condition.  Some offices feel they lack resources to address high-needs populations; some offices do not wish to attract such patients, politely ignoring that few clinics do not already count such patients among their loyal rosters.  Ironically, addictions treatment is not a difficult area of medicine to learn anew; still in its infancy, there are only a handful of drugs in limited regimens to effect change in addicted patients – making this field far less complex than, say, metabolic syndrome. An addicted patient should be able to walk into any primary care clinic in America and receive standard-of-care treatment on site – just as they would for hypertension or diabetes.

As long as addictions are marked as a condition to avoid and disdain, critical masses of providers needed to battle back the tide of narcotics abuse will not emerge.  Primary care must become the locus of outpatient treatment, with inpatient and/or specialty treatment reserved for the most ill or incorrigible cases.  Primary care training centers must teach evidence-based use of supported sobriety medications; states can support such resources by offering tax breaks to practices that provide rare services, as is currently proposed in New Mexico.

Addicts in recovery are a uniquely rewarding population – I can think of no other disease whose sufferers beg for their place among woefully inadequate programs, and profusely thank me for helping them wrest their lives back from the abyss of a difficult existence and early mortality.  These patients already haunt the halls of just about every clinic in the nation, quietly seeking help for a dependence that they may or may not admit to their physician.  Whether in high-prevalence crisis zones like northern New Mexico or in areas of average abuse, primary care owes it to our patients and our profession to face down this epidemic, to meet the challenges of our time.

Julie Craig is a family physician who blogs at America, Love It or Heal It.

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  • Donald Tex Bryant

    I agree that prescription drug abuse is a serious condition in the U.S. Recently, the Wall Street Journal ran a series of articles on this problem and the complex involvement of healthcare providers in it. One startling fact is that according to the WSJ and the CDC, opioid prescription drug overdose is the leading cause of accidental death in the U.S. now; more die from overdose than in automobile accidents.

    If you like, you can access the series of articles by going to Google News and typing in “WSJ investigation: The Prescription Painkiller Epidemic.” Many of the articles are research based.

  • Suzi Q 38

    I was given 60 (2 RX’s) of Norco after my anterior discectomy.
    It has been a month after my surgery (1/18), and I have used only 26-28 tablets.
    I weaned myself off by substituting plain Tylenol instead of the Norco.
    I would titrate the Norco down and stub the Tylenol very slowly.
    Now I am at 1 Tylenol BID, and today was the first day I did not take my AM Tylenol.
    I really like how the Norco feels at night, but I don’t want to become dependent on it.

  • encdinosaur

    I suspect that the author is not old enough to have been in practice less than 15 years ago when the national headlines were “Doctors Don’t Treat Pain Well Enough” and we had the introduction of the frowning or smiling faces, or the ten point pain scale, introduced as the “fifth” vital sign in the medical record.
    No doubt that there is abuse, but the pendulum is in the process of swinging too fast to the prior state of affairs.
    Those data on deaths by overdose should be broken down into overdoses by the patient for whom the drug was prescribed, rather than including instances of illegal use of drugs from diversion, and the consequences of such activity.

    • Julie Craig, MD

      After puzzling for some time over the content of this response, I might ask the question: are you referring to the content of the article, or the title only, which might imply that I hold primary care responsible for the prescription drug epidemic? My commentary has nothing to do with the source of drugs of abuse – only that substance abuse treatment should be a core piece of primary care, given the commonality of the disease and the lack of specialists to efficiently treat this problem. Incidentally, the title was changed prior to publication – I did not choose it.

      And yes, I am aware of the history of the opioid epidemic – that it has roots in both legal and illicit patterns of abuse, and that the pain movement (which followed closely on the heels of the HIV epidemic and the hospice movement) coincided unfortunately with the introduction of patented long-acting opioids (especially OxyContin) to meld good
      intentions and profit-making intentions with deadly results. I do question the utility of trying to suss out the exact source of overdoses – when I have frank discussions with patients desiring sobriety, a typical story might sound like this: started on pain pills after a car accident, pain was minor but still present after several months so meds were continued, eventually meds were tolerated and thus escalated, meds became too expensive or doctors became wary so the transition to cheaper heroin was initiated, still alternating with pills. The eventual overdose (or just daily usage) might be combination of prescribed pills (some prescribed to the user and some diverted from friends, family, or dealers), half of which are traded for greater doses of heroin, alternating with Suboxone when the street supply of drugs tightens up (which lowers the tolerance for opioids if used for a length of time and unfortunately increases the overdose risk if a person returns immediately to prior doses). I have had patients report that they use cocaine or methamphetamines when their primary opioid is in poor supply – anything to try to escape the terror of withdrawal. Sussing out whether providers or street supplies are responsible seems like parsing matches when the house is burning. And none of that excuses physicians from playing appropriate roles in preventing and treating substance abuse: prescribing judiciously and appropriately when indicated, and treating the separate affliction of addiction as it arises.

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