Should Medication-assisted Treatment Be Part of Primary Care?

July 28, 2017 03:21 pm News Staff

Although most family physicians may agree that medication-assisted treatment (MAT) is an essential component of caring for patients with addiction, the question of whether they should incorporate MAT into their practices ignites debate.

[Pill bottle with tablets spilling out on table next to syringe and pile of powder]

A family physician( and a psychiatrist( squared off on the issue in a point/counterpoint in the July/August issue of Annals of Family Medicine.

For FP David Loxterkamp, M.D., of Belfast, Maine, there's no dispute about family physicians' fitness to provide these services: "No one is better qualified to treat addiction than a family doctor."

He told the story of Amanda, a 19-year-old woman whose father called him from the ER to say she was suffering from a stomach virus. In private, Amanda told Loxterkamp that she actually was withdrawing from heroin.

Loxterkamp, who did not know about MAT at the time, was able treat her immediate medical needs but not the addiction that brought her to the ER, and she visited the ER two more times before entering an addiction treatment program.

The experience had a profound effect on Loxterkamp, prompting him to obtain training to prescribe Suboxone (naloxone and buprenorphine). He subsequently expanded his practice to include addiction medicine.

"That was my conversion experience," he wrote in Annals. "Getting involved often requires a personal hook: one patient; a confrontation with the brutality of the disease; the certainty you were chosen to make a difference."

Today, caring for patients with addiction is a calling for Loxterkamp, driven by personal experiences, including knowing that his sister "dabbled in drugs," and by understanding that patients with addiction are looking for someone to confide in -- often a family physician.

Cleveland psychiatrist Richard Hill, M.D., however, cautioned that primary care physicians should be wary of taking on yet another complex patient population.

According to Hill, patients who need MAT probably have already exhausted nonmaintenance treatment interventions and are more likely to have other mental health needs.

"The opioid-dependent patient population being considered for buprenorphine treatment in primary care settings therefore represents a more severe and treatment-resistant population that requires specialist intervention," he wrote.

Hill pointed out that primary care physicians who treat moderate cases of diabetes and hypertension may refer more severe cases to specialists, and he advocated the same protocol for patients who require MAT.

He also warned that taking on this burden could exacerbate physician burnout, because primary care physicians are "already overworked and don't need another major initiative to further divide their attention from their current caregiving roles."

Loxterkamp acknowledged that opening the doors to this complex patient population requires physician leadership and a commitment to team-based care.

Still, he wrote, "Addiction is a chronic disease that is decimating our communities. We need no other reason to embrace its treatment within every primary care practice. Yes, it will require a special workflow, but so does the management of diabetes or depression."

For his part, Hill advocated that more research on the effectiveness of MAT be conducted, and he called on policymakers to bolster the availability of mental health and addiction treatment facilities.

"Even if further research establishes an 'optimal' model of care for use in primary care, the nature of the disease itself will place undue clinical burden on an already overextended clinical workforce," he wrote. "Perhaps future efforts and funding should be directed toward the development of readily accessible referral networks of mental health/addiction centers, both public and private."

Although Loxterkamp acknowledged that there is "a critical need for informed public health policy," he insisted that physicians on the ground are the ones best able to fashion a community-based response to the opioid epidemic.

In the 12 years since he started down this road, Loxterkamp has treated hundreds of patients addicted to opioids, and he spoke plainly about his reasons for continuing this work.

"I am still involved because I am a doctor and this is the epidemic of our time, a social tsunami that can be traced to my prescription -- and yours," he wrote. "I am involved because it restores my faith in family medicine, where relationships still matter."

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