Preparations for Treating Opioid Use Disorder in the Office

 

Use this guide to plan for offering medication-assisted treatment with buprenorphine.

Fam Pract Manag. 2018 Nov-Dec;25(6):21-26.

Author disclosures: no relevant financial affiliations disclosed.

Related article from American Family Physician: "Buprenorphine Therapy for Opioid Use Disorder.”

Opioid use disorder (OUD) affects all segments of the U.S. population.1,2 The impacts of OUD and opiate misuse are severe, leading to dramatic declines in public health and quality of life, including increased rates of overdose and death. In 2016, more than 11.5 million people in the United States age 12 or older misused opiates in the past year, and approximately 2.1 million people age 12 or older had an opioid use disorder.2 From 1999 to 2016, approximately 632,000 Americans died of drug overdose, and more than half of those deaths were due to opioid overdose.3 From 2015 to 2016, opioid overdoses accounted for two-thirds of all drug overdose deaths.3

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in 2013 updated the diagnostic criteria and terminology for OUD4 and replaced the more stigmatizing terms of “opioid abuse” and “opioid dependence” with “opioid use disorder.” Describing the problem as a disorder empowers patients, providers, and payers to focus on treatment options in the clinical domain.

Prescription opioids are a key contributing factor to the rise of OUD in the United States. The Centers for Disease Control and Prevention (CDC) estimates that physicians wrote 259 million opioid prescriptions in 2012, enough for each U.S. adult to have a prescription.5 Additionally, the emergence of synthetic opioids such as illicit fentanyl has resulted in a recent and dramatic surge of overdose deaths.6,7

The opioid crisis calls for physicians not only to follow best practices for the responsible prescribing of opioid painkillers5 but also to provide treatment options where prevention has failed. Medication-assisted treatment (MAT) is an important part of the solution. MAT improves outcomes, reducing OUD morbidity and mortality, as well as societal problems associated with untreated OUD.8 Family physicians write more opioid prescriptions by volume than any other specialty,9 yet most family physicians don't prescribe MAT and feel ill equipped to address OUD.10 Recent policy developments and advances in MAT offer family physicians the opportunity to rise to the challenge of treating OUD in the office. The authors collectively have more than 14 years of experience providing OUD MAT treatment services with buprenorphine in practice and, along with other family physicians,11 have found this work to be humbling, gratifying, and an antidote to burnout. This article will present a guide to integrating MAT with buprenorphine into your practice.

KEY POINTS

  • Family physicians write more opioid prescriptions by volume than any other specialty, yet most family physicians don't provide medication-assisted treatment (MAT) for patients with opioid use disorder.

  • MAT with buprenorphine is an effective alternative to methadone that can be provided in primary care practices by family physicians who complete eight hours

ABOUT THE AUTHORS

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Dr. Kowalchuk is associate professor in the Department of Family and Community Medicine at the Baylor College of Medicine in Houston....

Dr. Mejia de Grubb is assistant professor in the Department of Family and Community Medicine at the Baylor College of Medicine in Houston.

Dr. Zoorob is professor and chair of the Department of Family and Community Medicine at the Baylor College of Medicine in Houston.

Author disclosures: no relevant financial affiliations disclosed.

References

show all references

1. American Academy of Pediatrics Committee on Substance Use and Prevention. Medication-assisted treatment of adolescents with opioid use disorders. Pediatrics. 2016;138(3):e20161893....

2. Key Substance Use and Mental Health Indicators in the United States: Results From the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17–5044, NSDUH Series H-52) Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2017. https://www.samhsa.gov/data/sites/default/files/NSDUHFFR1-2016/NSDUH-FFR1-2016.htm. Accessed September 3, 2018.

3. Seth P, Scholl L, Rudd RA, Bacon S. Overdose deaths involving opioids, cocaine, and psychostimulants – United States, 2015–2016. MMWR Morb Mortal Wkly Rep. 2018;67349–358.

4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.

5. Opioid painkiller prescribing. Centers for Disease Control and Prevention website. http://www.cdc.gov/vitalsigns/opioid-prescribing/index.html. September 5, 2018. Accessed September 8, 2018.

6. Overdose death rates. National Institute on Drug Abuse website. https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. August 2018. Accessed September 3, 2018.

7. Vivolo-Kantor AM, Seth P, Gladden RM, et al. Vital signs: trends in emergency department visits for suspected opioid overdoses – United States, July 2016–September 2017. MMWR Morb Mortal Wkly Rep. 2018;67(9):279–285.

8. Medication and counseling treatment. Substance Abuse and Mental Health Services Administration website. https://www.samhsa.gov/medication-assisted-treatment/treatment. September 28, 2015. Accessed September 3, 2018.

9. Chen JH, Humphreys K, Shah NH, Lembke A. Distribution of opioids by different types of Medicare prescribers. JAMA Intern Med. 2016;176(2):259–261.

10. Crothers J, Petterson S, Bazemore A, Wingrove P. Family medicine: an underutilized resource in addressing the opioid epidemic? Am Fam Physician. 2016;94(5):350.

11. Gastala N. Denial: the greatest barrier to the opioid epidemic. Ann Fam Med. 2017;15(4):372–374.

12. Medication and counseling treatment: methadone. Substance Abuse and Mental Health Services Administration website. https://www.samhsa.gov/medication-assisted-treatment/treatment/methadone. September 28, 2015. Accessed September 4, 2018.

13. McNicholas L. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction: A Treatment Improvement Protocol, TIP 40. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004. https://www.naabt.org/documents/TIP40.pdf. Accessed September 4, 2018.

14. Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;2:CD002207.

15. Walsh SL, Preston KL, Stitzer ML, Cone EJ, Bigelow GE. Clinical pharmacology of buprenorphine: ceiling effects at high doses. Clin Pharmacol Ther. 1994;55(5):569–580.

16. Welsh C, Valadez-Meltzer A. Buprenorphine: a (relatively) new treatment for opioid dependence. Psychiatry (Edgmont). 2005;2(12):29–39.

17. Johnson RE, Strain EC, Amass L. Buprenorphine: how to use it right. Drug Alcohol Depend. 2003;70(2 Suppl):S59–S77.

18. Johnson RE, Jones HE, Fischer G. Use of buprenorphine in pregnancy: patient management and effects on the neonate. Drug Alcohol Depend. 2003;70(2 Suppl):S87–S101.

19. Korthuis PT, McCarty D, Weimer M, et al. Primary care-based models for the treatment of opioid use disorder: a scoping review. Ann Intern Med. 2017;166(4):268–278.

20. Olson Y, Sharfstein JM. Confronting the stigma of opioid use disorder – and its treatment. JAMA. 2014;311(14):1393–1394.

21. Qualify for a physician waiver. Substance Abuse and Mental Health Services Administration website. https://www.samhsa.gov/medication-assisted-treatment/buprenorphine-waiver-management/qualify-for-physician-waiver. November 21, 2016. Accessed September 4, 2018.

22. Billing and coding: medication assisted treatment. IT MATTTRS Colorado website. https://www.asam.org/docs/default-source/education-docs/billing-and-coding-format_it-matttrs_8-28-2017.pdf. August 28, 2017. Accessed September 26, 2018.

 
 

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