Moving Opioid Addiction Treatment to Primary Care

Bringing buprenorphine treatment into primary care settings could help combat the opioid epidemic, according to the authors of three perspective articles published online July 5 in the New England Journal of Medicine.

"We are in the midst of a historic public health crisis that demands action from every physician," write Sarah E. Wakeman, MD, and Michael L. Barnett, MD, both from Harvard University, Boston, Massachusetts.

"Mobilizing the PCP [primary care physician] workforce to offer office-based buprenorphine treatment is a plausible, practical, and scalable intervention that could be implemented immediately.... PCPs have the clinical skill and grit to take on this challenge."

According to Jeffrey H. Samet, MD, MPH, from the Boston University Schools of Medicine and Public Health and Boston Medical Center, Massachusetts, and colleagues, expanding the availability of addiction medications into primary care to treat opioid use disorder will be key to stemming the epidemic of overdose deaths.

Nevertheless, although approximately 2.1 million people in the United States have an opioid use disorder, only about one fifth of these receive treatment.

Stigma related to the nature of addiction and medication-assisted treatment are largely to blame. Molly Rutherford, MD, MPH, from Bluegrass Family Wellness, PLLC, Crestwood, Kentucky, told Medscape Medical News that most PCPs have no idea how to approach substance use disorders. "There is stigma within the recovery community around medication-assisted treatment, which further interferes with people accessing effective treatment."

Stigma also interferes in physicians' deciding to treat addiction, she explained. "Physicians assume that people with addiction will be 'difficult,' which I admittedly believed until I started treating people with addiction."

In addition, she noted that physicians are justifiably concerned about being targeted by the Drug Enforcement Administration. "Addiction physicians experience stigma similar to people struggling with the disease, and very few physicians willingly subject themselves to criticism by peers, media, and potentially law enforcement."

Growth of Buprenorphine Distribution Falling, Fatal ODs Rising

Methadone, buprenorphine, and naltrexone are approved by the US Food and Drug Administration (FDA) for treating opioid use disorder, write Brendan Saloner, PhD; Kenneth B. Stoller, MD; and G. Caleb Alexander, MD, all from Johns Hopkins University, Baltimore, Maryland. However, although all three drugs play important roles in managing opioid addiction, buprenorphine offers the greatest opportunity to expand treatment into primary care, because physicians can initiate treatment during an office visit while a patient is in withdrawal.

However, despite the growing availability of office-based addiction treatment since federal approval of buprenorphine, annual growth in buprenorphine distribution has been decreasing, instead of increasing, in response to demand. As a consequence, the opioid epidemic is worsening.

According to Wakeman and Barnett, opioid overdoses claimed the lives of 42,249 Americans in 2016, up 28% from the previous year.

To help fight this crisis, they stress that patients need to find it easier to get buprenorphine treatment than to get heroin and fentanyl.

Moving opioid addiction treatment to the mainstream could help facilitate this. Indeed, with 2017 estimates showing that more than 320,000 PCPs are treating US adults, PCPs are well positioned to deliver buprenorphine treatment.

In addition to allowing for provision of high-quality addiction treatment, primary care settings also allow clinicians to manage concurrent chronic conditions such as depression. PCPs can also comanage patients with specialty care providers, such as clinicians in opioid treatment programs or outpatient clinics.

"Expanding buprenorphine provision could have population-wide benefits," write Saloner and colleagues, "but as currently delivered, this treatment is not fully living up to its promise."

Persistent myths about buprenorphine treatment also continue to serve as barriers to its acceptance, say Wakeman and Barnett. These include misconceptions that it is more dangerous that other health interventions, it merely replaces one addiction with another, its delivery is burdensome and time-consuming for PCPs, abstinence-based treatment is more effective for treating addiction, and physicians should simply stop prescribing so many opioids to help curb the epidemic.

In addition, these myths underpin federal and state regulatory barriers that need to be addressed, Wakeman and Barnett say.

Treatment Availability Should Not Come at the Expense of Quality

"However, as public health officials and clinical leaders endeavor to decrease stigma against substance use disorder and its treatment by making it more mainstream in medical care, it is critical that we don't simply redirect that stigma by accepting mediocre treatment," Stoller told Medscape Medical News.

"People with substance use disorders deserve the highest-quality evidence-based care, just as do those suffering from other chronic disorders such as heart disease, cancer, or HIV/AIDS," he said. "Accepting anything less, including blaming patients for being 'treatment resistant,' when in fact, the treatment offered is inadequate, perpetuates the stigma that keeps substance-using patients from treatment, and that keeps primary care providers from prescribing."

He went on to emphasize that if increased access is achieved at the expense of treatment quality, patients will not achieve the low rates of continued substance use necessary to stem the tide of overdoses. "With fentanyl and even more potent analogues becoming increasingly pervasive in the drug supply, even brief lapses to drug use can prove fatal," Stoller stressed.

Ease Methadone Restrictions, Experts Say

Samet and colleagues explain how restricting methadone use to designated clinics has also added to the treatment gap. "This strategy has been locked in place because changing it requires an act of Congress."

Nevertheless, the increasing opioid epidemic could help propel changes in the law to allow expansion of methadone treatment into primary care settings, they say.

"The Controlled Substances Act could be amended to allow clinicians who have the required training to prescribe buprenorphine for opioid use disorder to also engage patients in methadone treatment for this condition in office-based settings."

Samet and colleagues highlight the successful use of methadone in patients who transitioned into a primary care–based program. The results were excellent, they say, and treatment proceeded without adverse incidents.

For one patient in the program, receiving methadone treatment and general healthcare in a primary care setting was "like winning the lottery — better actually."

Expanding methadone treatment into primary care will also require physicians to receive training on opioid use disorder, consideration of incentives for prescribing addiction treatment medications, and integration of treatment into current healthcare models.

"But the solution to a complex problem often begins with small, pragmatic steps," Samet and colleagues write.

Rutherford acknowledged that treating addiction and other chronic diseases requires time, continuity, and relationship. "Our current primary care environment, with 10-minute visits, onerous coding, billing, and [electronic medical record] requirements, is overwhelming for physicians and all providers, who will be reluctant to take on another challenge."

Nevertheless, she encourages PCP colleagues to treat addiction. "It is very rewarding and aligns with our role as PCPs," she said. "We are well trained at managing chronic disease, and we value continuity and relationship with our patients," she concluded.

One author has reported holding equity in Monument Analytics (whose clients include the life sciences industry as well as plaintiffs in opioid litigation), being a paid advisor for IQVIA, serving on the Advisory Board at MesaRx Innovations, being a member of OptumRx's National Pharmacy and Therapeutics Committee outside the submitted work, and serving as chair of the US Food and Drug Administration's Peripheral and Central Nervous System Advisory Committee. The remaining authors and Rutherford have reported no relevant financial relationships.

N Engl J Med. Published online July 5, 2018. Wakeman and Barnett full text, Samet et al full text, Saloner et al full text

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