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“We know regulators can move quickly to confront a health crisis because we have seen it in action. During COVID, the nation eased regulatory burdens at all levels of government to help health systems and doctors leverage technology and change the way they deliver care and to drive vaccine innovation. During the AIDS epidemic, we saw how effectively we could mobilize across the public and private sector to really change the course of the fight. Now is the time to harness the same energy for the opioid crisis.
When you begin multiplying the number of those who have died from overdoses by the number of friends and loved ones who cared about each person and are now experiencing life-altering losses, there are fewer and fewer Americans unaffected by this crisis. The status quo is not only failing people with opioid use disorder, it’s failing all of us.”
Arthur Robin Williams is a psychiatrist.
He shares his story and discusses his KevinMD article, “The status quo is failing people with opioid use disorder.”
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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.
Transcript
Kevin Pho: Hi, welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Arthur Robin Williams. He is an addiction psychiatrist, and he wrote the KevinMD article “The status quo is failing people with opioid use disorder.” Arthur, welcome to the show.
Arthur Robin Williams: Thanks so much for having me.
Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?
Arthur Robin Williams: Sure. So, you know, I grew up in the South, actually, in the ’80s and ’90s, and as with every part of the country, we were very much aware of the AIDS epidemic. That really piqued my interest in public health around HIV prevention and trying to understand infectious disease. By late high school, I was anticipating going to medical school but trying to work in the public health field, probably around ID. And then in college, I had some experiences in developing countries working on HIV prevention efforts, which actually rerouted my interest in terms of domestic health policy.
I was at Princeton for college. I was in New Jersey, and we had the highest rate of mother-to-child HIV transmission in the country, which was a very odd thing. We had big public health institutions. We were surrounded by big cities, New York, Philadelphia. It was one of the wealthiest states in the country. How could this be happening in the northeastern United States? A lot of it was about policy, and it was really drug policy, because the Northeast had clamped down in the ’70s, during the heroin epidemic, on access to syringes: buying them over the counter without a prescription, being in possession without a prescription, paraphernalia laws that were actually causing more harm than good. And so my interest pivoted to drug policy and addiction treatment, and that’s how I wound up ultimately as an addiction psychiatrist and researcher.
Kevin Pho: So as an addiction psychiatrist, tell me a little about the cases that you see and a typical day for you.
Arthur Robin Williams: It totally runs the gamut. I often tell my friends and colleagues, I think my week goes by quicker than almost anyone else’s week. So most of my time is on research. I have a portfolio of NIDA- and SAMHSA-funded research, mostly related to the opioid crisis. And then I also see my own patients in the evenings once or twice a week, and I’m also a consultant and an advisor to others, to the residents at Columbia, and to Ophelia Health, for instance, which is a telehealth company for opioid use disorder treatment. So it’s a total array of patient care and thinking about patient journeys, and I love the mix.
Kevin Pho: And when it comes to opioid use disorders, what are some of the most challenging or common issues that you typically see in your practice?
Arthur Robin Williams: Yeah, it really depends on how you think about it. So in terms of clinical practice for myself, you know, I’m in a really privileged position where I’m seeing private patients in New York City, so this is not a representative group. Having trained at NYU and at Bellevue, and having worked in the largest public health system in the country, here in New York City, for years, especially in the emergency room, I think the big challenge and the big failure, frankly, of our system is that we have individuals who rise to our attention, whether it’s in an emergency department or in a jail, while people are in prison, pre-release, post-release. In the system, we have all of these sort of golden windows of opportunity to connect people to care, and historically, we haven’t done it. So we really have an access issue in the U.S., which is not just about the availability of services but also the affordability of services.
Kevin Pho: All right, let’s transition into the KevinMD article that you wrote. It’s titled “The status quo is failing people with opioid use disorder.” And for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?
Arthur Robin Williams: Clearly, one of the catalysts was last year, in 2021. As of April, CDC announced we now have over 100,000 overdose fatalities on an annualized basis, and that’s continued for seven months in a row now. Literally just yesterday, the CDC announced that as of October 2021, we now have over 105,000 overdose deaths, and the great majority are from fentanyl, which is really shorthand for fentanyl and fentanyl-related analogues, or these other really potent synthetic opioids, often now used in combination with other drugs. One of the phenomena that has become more apparent is that these compounds, fentanyl, are so sedating that users are reporting that they’re using psychostimulants like crystal methamphetamine and cocaine in order to stay awake, because the fentanyl otherwise is making them so sedated.
One thing that’s lost is that fentanyl doesn’t just lead to respiratory suppression, like any full agonist opioid could, but it can also cause sort of inflammatory and hardening reactions in the chest and the lungs. So the overdose happens much more quickly. It’s much more resistant to naloxone reversals, and so it’s really just driving these skyrocketing overdose rates.
Part of my frustration in terms of writing this article is that we’re now 20-plus years, 25 years, into an opioid epidemic. And when you look at what we were able to do with COVID, massive regulatory reform basically within a week: SAMHSA rewrote all of the rules, especially for methadone programs. The Ryan Haight Act has been suspended under the public health emergency, for the most part. Massive, sweeping reforms, and it was because of a virus. It wasn’t because of the opioid crisis itself.
Kevin Pho: So tell me, from a policy standpoint, what would you like to see done to help stem the fentanyl-driven opioid crisis?
Arthur Robin Williams: I think we need to be really creative and innovative. As a sort of critic here, using a critical lens, what I would say is that we’ve more or less done more of the same over the last 25 years. People in this field know that SAMHSA funds the Substance Abuse Prevention and Treatment Block Grants, or the SAPT Block Grant. A lot of people mistakenly think that that’s the number one source of funding for addiction treatment in the United States, and that’s been sort of topped off. When you think about inflation, if you adjust for inflation, we really haven’t even increased our spending that much over the last 20 years.
The big problem is that, in general, our public funds are going to treatment programs that are doing the same thing they were doing 20 years ago. And the great majority, easily 60, 70 percent, of care episodes for opioid use disorder in the United States don’t use evidence-based medication. The first-line treatments are these three FDA-approved medications, methadone, buprenorphine, or naltrexone, and yet the majority of the time, patients don’t get these medications. It’s totally appalling.
You imagine someone with diabetes going in, the modal patient with diabetes, and they are refused insulin because their counselor has an ideological bias against insulin-based medications. We’d have a huge, huge problem around diabetes, in a way that we don’t, because the standard is evidence-based care. With opioid use disorder, the standard of care is not evidence-based. It’s 12-step, and a lot of that reflects this sort of historical inertia around treatment for alcoholism, which doesn’t translate to the treatment for opioid use disorder.
Kevin Pho: So I’d like to have you go into more detail in terms of some of those obstacles and resistance points preventing these evidence-based solutions to overdoses. So why aren’t these medications being used?
Arthur Robin Williams: Unfortunately, it’s probably culture and stigma. And historically, a lot of our rehab programs, and we have about 15,000 addiction service programs in the United States, maybe 1,500 are methadone programs, 1,000 are hospital-based, so the great majority, 10,000, 12,000 of these programs, you could think of along the lines of mom-and-pop, small-scale sober houses, 12-step programs, therapeutic communities. People may be residential. They may be in what we might think of as more of an intensive outpatient program. These are basically groups. They’re peer-led groups. They may have counselors who are running the groups, and they’re 12-step-based. So it often, unfortunately, is ideological, in the absence of having access to medications.
And part of that reflects the reimbursement, the funding streams, where these programs don’t actually have the funds to hire nurses and physicians, and they’re not providing medical care, so they’re not eligible for insurance reimbursement from a Medicaid plan or a commercial plan to begin with. So the addiction world has increasingly been separated, right, segregated from academic medical centers. They’re not co-located on the same campuses, in the same buildings. And often, especially historically, the plans carved out behavioral health and had all sorts of limits. So the Parity Act, which now was well over a decade ago, really hasn’t had much teeth, because it hasn’t been enforced. So we have separation in where the services are, separation in the payment for it, and people often aren’t receiving evidence-based care. It’s a major problem, and it really hasn’t changed that much in the last 20 years.
Kevin Pho: So if a patient comes to the emergency room with an opioid use overdose, a fentanyl-driven opioid overdose, in your ideal world, what should be done if a patient comes to the emergency department with that scenario?
Arthur Robin Williams: So that’s a crisis scenario, and the crisis is not just reversing the overdose. That’s not addiction treatment. That’s treating a medical complication from an untreated opioid use disorder. It’s really a crisis in terms of how to keep this person alive, because easily 10, 15 percent of those people are going to be dead within the next year. They’re at least going to have another medically treated overdose in the ED, if not die. And what’s emerged in the literature just in the last year or two is that among people who have a medically treated overdose in the emergency room, we know there are exceptionally high rates of one-year mortality following that event. A lot of that’s driven by overdose, but half of it is driven by other causes of death. So these are people who are at extremely high risk of death, from injuries, from suicide, from other chronic conditions.
One of the things that’s also emerged in studies recently is not just that medication can reduce the risk of overdose while people are on it by 60, 70, 80 percent. It can also reduce the risk of all-cause mortality, from cancer, from cardiovascular disease, from all these other causes of death. So these are really stabilizing medications that offer tons of benefits to patients, and it’s just a travesty when patients aren’t connected to first-line treatments, the gold standard treatment, which is going to be methadone, buprenorphine, or naltrexone.
So in the best-case scenario, someone’s treated for a medically treated overdose in the ED. We want to make sure they have access to medication, which is not being given a list, a Google-based list that someone pulled off the internet of local AA meetings or NA meetings. That’s not connecting someone to treatment. Ideally, they’d be inducted on buprenorphine in the emergency room itself. They might be started on an injectable, such as extended-release naltrexone. We now have one, and hopefully soon two, versions of injectable buprenorphine that could be administered before the patient is discharged. But that’s not our standard of care, and there’s really not an excuse for it.
Kevin Pho: So in order to make that the standard of care in terms of addiction treatment, is it a matter of funding? What needs to be done to change that culture? Is it a matter of access? So tell me what needs to be done to make that next step.
Arthur Robin Williams: It’s a long list. So funding, of course, matters. We have to think about the financial incentives of the hospital, of the ED department, of the individual clinicians within the ED. They don’t have to think about the insurers. Typically, these patients are covered by a public plan, maybe a commercial plan, and then plenty of them are out of pocket, but it’s not necessarily because they’re ineligible for a Medicaid plan. They’re just not actively enrolled.
And then there are, of course, patient-level barriers as well. A lot of patients think, you know, they’ve had this harrowing experience. They’re maybe sure this will never happen again because they almost died. So they leave resolute that they’ll never use again, or they’re going to decide, probably wrongly, unfortunately, that they’re going to control their heroin use or their drug use going forward and not let this happen again. And the reality is, unless people start medication, they’re more or less doomed to escalating amounts of opioid use and adverse events that will keep happening.
Kevin Pho: So I’m a primary care physician, and if one of my patients had an overdose and I wanted to connect them with someone who offered these long-term medication treatment options, what can I do to look for these resources?
Arthur Robin Williams: So there are more and more resources online, and there are all sorts of treatment locators. SAMHSA, the Substance Abuse and Mental Health Services Administration, under the U.S. Department of Health, has a SAMHSA-based treatment locator online, a registry of buprenorphine-waivered prescribers in the U.S. Not a surprise, it’s really hard to maintain such a big directory and have it be accurate and accurately reflect who’s actually available to treat patients, who’s accepting patients based on which form of insurance they might have.
There are additional resources. The Providers Clinical Support System, PCSS, is a SAMHSA-funded program that the American Academy of Addiction Psychiatry, the AAAP, has been spearheading for several years now. There’s the Opioid Response Network. This is a new initiative in the last few years that SAMHSA’s funding, and it builds on the backbone of the ATTC infrastructure of the U.S. So there have been concerted efforts to help provide technical assistance to providers and to states, to help them be aware of what is available. I think that the bigger issue is that we have an under-resourced system, and especially in rural areas, we just don’t have providers.
Kevin Pho: We’re talking to Arthur Robin Williams. He’s an addiction psychiatrist. He wrote the KevinMD article “The status quo is failing people with opioid use disorder.” So, Arthur, as I said, I’m in primary care, and we have a lot of primary care clinicians who listen to this podcast. From your perspective as an addiction psychiatrist, do you have any tips, wisdom, and advice that we in primary care can give in the exam room to our patients who may be suffering from an opioid use disorder?
Arthur Robin Williams: Yeah, I think that there was this great hope when the ACA passed that we would be better able to screen and diagnose opioid use disorder in primary care settings. And actually, I’ll challenge your question a little bit. I think that that can happen, and we should be screening and trying to refer people to specialized services. I think the bigger problem is that a lot of these patients are kind of floating out on their own, and they’re disconnected from regular care. So I think one of the big opportunities in primary care settings is, when patients come in and you have a new patient intake who’s on buprenorphine, or who’s going to a methadone program, or who’s on extended-release naltrexone, to be open to treating that patient the same way you would openly accept and treat any other patient who doesn’t have an addiction history. I think that might be an area where primary care could be especially beneficial.
I think partnering with OTPs, opioid treatment programs, or how we now refer to methadone programs, can be really beneficial, looking to grow this network to try to improve communication streams. Clearly, if services are provided in different settings, often we have barriers in terms of sharing records. There’s not only HIPAA but concerns about how CFR 42 Part 2 constrains our ability to share information between providers when patients are receiving addiction treatment services. But this is something that’s been a bit controversial. It’s been debated in recent years. Does that need to be done away with? Reformed? How can we protect patient confidentiality while also not inhibiting providers’ ability to be aware of what patients are receiving in terms of treatment and what they need?
So I do think there are a lot of opportunities, but I wouldn’t say that the first challenge is that primary care doctors aren’t diagnosing opioid use disorder. I think we actually have other challenges that are more at scale and more proximal.
Kevin Pho: And if primary care clinicians want more training so they can prescribe long-term naltrexone and buprenorphine, what kind of training do they need?
Arthur Robin Williams: So SAMHSA last April put out updated guidance rules that anyone now with a DEA license can submit a notice of intent and, without going through the eight-hour training for a physician or the 24-hour training for a nurse, can get an X-waiver from SAMHSA and treat up to 30 patients with buprenorphine. So the training’s no longer required for up to 30 active patients on buprenorphine. Clearly, the training is still widely available. There are many, many ways to access this training for free. And then physicians and nurses, if they complete the requirements, can have up to 100 patients on buprenorphine, which would be a big contribution.
What we’ve learned, though, and this is one, two decades now of training clinicians and getting them waivered, is that people, you know, think of this sort of truism: If you don’t prescribe it in residency, you never prescribe it. And that’s true for so many things. It’s certainly true for buprenorphine. If we have residents who graduate from their programs, primary care, emergency medicine, internal medicine, psychiatry, and they’ve never administered an extended-release naltrexone injection, they’re probably not going to do it anytime soon.
So I think what we need is more active learning, and not just sitting through eight hours of webinars, right, or just reading some articles. What really changes provider behavior is having a mentor who supervises cases. And I would hope that there are a lot of primary care doctors who want to be more involved, to see this as an area that they haven’t been as involved in. In order to move forward, I would say get a mentor. Talk to a colleague who’s actively doing this. I think it’s daunting, and it’s the activation energy. Once a provider starts prescribing buprenorphine or gives the first extended-release naltrexone injection, they’re way more likely to keep doing it. So it’s really about the first or second patient.
This is not actually complicated. I think people get a little bit apprehensive, but once you’ve seen a few patients, people run with it. And I think part of that, too, reflects how exciting it is to work with these patients, because the medications often have such a big effect size that people can look totally different in two or three weeks, and they can transform their lives in just a few days or weeks. So there’s kind of this magical aspect to the care, where it’s not curative by any means, but it’s transformative.
Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?
Arthur Robin Williams: Well, you know, on methadone, I was thinking about this leading up to our interview, Kevin, and I would say the person who right now has the biggest influence on our methadone programs in the United States is Richard Nixon. I mean, it really hasn’t been since the Nixon White House that we’ve had major changes to how methadone is accessed in the United States. It took an act of COVID to change how people access methadone in the United States, and again, it wasn’t because of the opioid crisis. It was because of this viral pandemic. So I think there’s been a lack of imagination, and we really need sweeping reform.
And because of COVID, one of the real breakthroughs here is telehealth, and that’s not just for addiction treatment or mental health treatment. We’ve seen all sorts of systems, all sorts of providers, convert to telehealth, and I think one of the big surprises is that it can be superior. There are benefits, unanticipated benefits, to this. No-show rates are much lower across all specialties that have converted to telehealth, and there are ways to connect with patients who otherwise wouldn’t be receiving services at all by the creation of these teleplatforms and digital-first treatment platforms.
So I think there are some ways that we realized we can be thinking much bigger and much bolder in terms of the kind of change we need, especially for underserved and more rural and frontier county areas. There are all sorts of things we could be doing. We just need to give ourselves permission to do it.
Kevin Pho: Arthur, thank you so much for sharing your time and insight. Thanks again for being on the show.
Arthur Robin Williams: Thank you.
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