PCPs Don't Back 'Gold Standard' Treatment for Opioid Addiction

Batya Swift Yasgur, MA, LSW

April 20, 2020

Despite conclusive evidence showing that medications such as buprenorphine are the gold standard treatment for opioid use disorder (OUD), a significant proportion of primary care physicians (PCPs) aren't buying in, results from a nationally representative survey show.

Investigators found one third of US primary care physicians do not believe medications used to treat OUD are more effective than nonpharmacologic treatment or that they are safe for long-term use.

But even PCPs who do believe medically assisted treatment (MAT) is effective have little interest in treating OUD and show low support for policies that allow office-based physicians to prescribe methadone or those that would eliminate the buprenorphine waiver.

Medications such as buprenorphine and methadone are by far the most effective approach for OUD, but primary care physicians appear resistant to this message, lead investigator Beth McGinty, PhD, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, told Medscape Medical News.

"This may reflect longstanding misconceptions and negative biases about medication for OUD — for example, the incorrect idea that [these medications] replace one addiction with another," she said.

The results were published online April 20 in the Annals of Internal Medicine.

Most Go Untreated

"The large majority of people with OUD in the United States do not receive any treatment," McGinty noted.

Since many patients get most of their medical care from primary care physicians, increasing the degree to which primary care physicians prescribe medication for OUD is a public health priority, but no prior research has examined primary care physicians' views about medication for OUD," she added.

To fill this knowledge gap, the researchers sent out questionnaires to a random sample of 1000 US physicians drawn from a large physician database.

Eligible respondents were family, internal, or general medicine physicians. Of 668 eligible physicians, 361 (54%) responded. Surveys with more than 50% of data missing were excluded from the analysis (n = 25).  

The highest percentage of respondents were between ages 45 and 54 years, followed by ages 55 to 64 years, and 35 to 44 years at 29.4%, 28.5%, and 19.1%, respectively.

The authors note that the respondents had "nationally representative" characteristics.

Just over two thirds (67.1%) believed that treatment of OUD with medication was more effective than without and 63.7% believed patients can safely use medication to manage OUD in the long-term.

Buprenorphine was the first choice (77.5%) vs methadone (62.1%) or injectable extended-release naltrexone (51.4%). However, despite these findings few physicians reported prescribing buprenorphine (7.6%) or naltrexone (4.0%) for OUD.

Disturbingly, only 20.2% expressed any interest in treating patients with OUD; only 10% had buprenorphine waivers and only 11.8% expressed interest in obtaining a buprenorphine waiver.

Although most physicians supported increasing insurance coverage (81.8%) as well as government investment in OUD medication (76.4%), fewer than half (47.7%) were in favor of allowing physicians to prescribe methadone for OUD in primary care settings. In addition, only 38% supported eliminating the buprenorphine waiver requirement.

"Our survey data does not allow us to directly answer why physicians do not perceive medication as effective, despite conclusive evidence that it is, but there are likely a range of reasons, including lack of training and related discomfort in treating patients with OUD in general and with medication specifically," said McGinty.

"Some primary care providers may view OUD treatment as outside their purview and prefer to refer to specialists. Prior studies have also shown that many primary care providers hold stigmatizing attitudes about people with OUD, so stigma may play a role," she added.

Good News?

Commenting on the study for Medscape Medical News, Yih-Ing Hser, PhD, professor-in-residence, Department of Psychiatry and Behavioral Sciences, University of California, Los Angeles, called primary care physicians a "critical workforce that can help treat the nation's huge number of patients with opioid use problems."

For this reason, "their beliefs and attitudes about the medication treatment for OUD are important to know."

Hser, who was not involved in the research, said that although the report "appears to highlight the pessimistic aspects of the findings, I actually think it's good news that a high percentage of the respondents agree with the effectiveness of buprenorphine, which is a considerable improvement over 10 or 20 years ago."

Also commenting on the study for Medscape Medical News, Stephen R. Holt, MD, director of Yale School of Medicine's Addiction Recovery Clinic, New Haven, Connecticut, called it "disheartening but unsurprising."

In contrast to Hser's view, Holt said despite indisputable evidence that MAT for OUD is the gold-standard approach, "the needle has barely changed in the past decade."

A "Mind Blower"

Holt, who was not associated with the study, said, "It blows my mind that one third of licensed, trained physicians don't recognize the role of buprenorphine, naltrexone, and methadone in treating OUD — it would be as if of one third of primary care physicians don't think that insulin is good for diabetes."

He emphasized the role of stigma in the reluctance of primary care physicians to prescribe medication for OUD.

"I've asked some primary care physicians if they have thought of getting a buprenorphine waiver. Some have responded, 'I don't want those kinds of patients in my practice,' or 'My nurses won't want these folks in the waiting room,' " he said.

Holt said he and colleagues at Yale now introduce medical students at the beginning of their training to a patient recovering from OUD or alcohol use disorder.

"The students see a human being who is going through daily struggle to suppress cravings, which helps them develop a sense of compassion for a population that is otherwise largely stigmatized, discarded, and viewed as moral failures, as they might see someone with diabetes who is fighting to keep blood sugar under control," he said.

"You can't expect students to develop empathy if they only see these patients at the worst, when they are withdrawing, delirious, or agitated," Holt added.

McGinty agreed.

"It is critical to train primary care physicians on how to treat OUD," she stressed. "This training should be embedded in core medical school and residency programs and offered through continuing medical education opportunities."

The survey was funded by the Johns Hopkins University President's Frontier Award. McGinty, Hser, and Holt have disclosed no relevant financial relationships.

Ann Intern Med. Published online April 20, 2020. Abstract

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