Over 2 million Americans abuse or are dependent on prescription pain medications. These patients are in the office of every physician in the country, but only 3 percent of primary care providers offer them treatment.
Many patients are being given a sympathetic apology, a hotline to call, or a dead-end referral. Some of them are being sent to methadone clinics, which are often impractical, already-full, or deeply stigmatized. Others make their way to addiction specialists with long waiting lists, high fees, or other obstacles. Most, however, never get the chance to discuss their potentially life-threatening condition with their doctor at all. And this is an enormous missed opportunity.
There has been important attention lately from both the CDC and FDA about safer prescribing of opioids, acknowledging our role in preventing addiction. But what are we going to do about the millions of individuals already living with opioid use disorder? Do we not have an equal responsibility to treat this condition as we do in preventing it?
During my residency training in family medicine, I cared for a patient who had been on pain medications for many years, started by an outside specialist after decades of arthritis and failed back surgeries left her in unrelenting pain. After slowly building trust while tending to her diabetes, cholesterol, and other conditions, we had a conversation about the risks of being on high dose opioids for so long. To my surprise, she agreed that she was likely addicted at this point and confessed to her own fears of withdrawal, and the stigma of seeking help.
She stated simply: “I wish you could help me. You take care of everything else I’ve got, after all.”
Another, younger patient, who I saw regularly in caring for his hepatitis and depression, struggled to find effective treatment for his heroin dependence. With a wife and daughter, also my patients, he desperately wanted to get clean and asked, “Why can’t you just treat me here?”
Addiction treatment has long belonged to addiction specialists. As a primary care doctor, these are some of my most trusted and talented consultants. But access to their services is extremely limited, mainly due to their sparse numbers. Alone, they simply cannot meet the demand for treatment for opioid-dependent patients.
The tools to treat opioid use disorder already exist within the primary care. Buprenorphine therapy was approved by the FDA in 2002 and was designed specifically for use in the outpatient care setting. It has been proven safe and effective. It is uniquely suited for the kind of doctor-patient relationship that we are privileged to have in primary care.
But despite this evidence and availability, uptake by medical providers — particularly in primary care — has been slow. With the opioid overdose death rate quadrupling in the decade between 1999-2008, our collective unwillingness to embrace this modality grows increasingly indefensible.
Recognizing the needs of patients under my care, now and in the future, I undertook the training for buprenorphine prescribing. It involved an 8-hour online course, after which I applied for a special waiver from the DEA that allows me to prescribe the medication. A small effort, with a large reward.
To be sure, treating opioid addiction in primary care is daunting. Many barriers exist to physicians offering buprenorphine, beyond the small hurdles of the certification. Common challenges are insufficient mental health support services and inadequate staff training. And certainly, who can fault a primary care provider for balking at the idea of addressing even more within the confines of a 15-minute office visit?
But we need to think about opioid use disorder like we think of diabetes. Both are common chronic conditions with high rates of complication. We treat diabetes in primary care every day without much fuss. We appreciate having a diabetes specialist to refer unstable patients to, and consult a clinical pharmacist when insulin management gets complicated. But if we waited to treat all our diabetic patients until they saw a specialist, we’d have a lot more sick diabetics on our hands. Much in the same way, we need primary care providers to take on the routine treatment of patients with opioid use disorder. And systems must evolve to better support them in this pursuit.
As a profession, we accept our responsibility to meet the treatment needs of our patients. This is most urgent for those needs that are both imminently life threatening and drastically unmet. It is no longer acceptable to say that treating opioid use disorder in primary care is outside our “scope of practice.” We have the tools, and the imperative to use them grows every day. If the CDC and FDA acknowledge our role in preventing this devastating illness, it is high time we embrace our critical role in treating it.
Alicia Agnoli is a family physician.
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