Three articles published in the July 5 issue of The New England Journal of Medicine suggest a common-sense weapon against opioid-use disorder and the stigma of addiction: well-mobilized family physicians.
"Primary Care and the Opioid-Overdose Crisis -- Buprenorphine Myths and Realities,"(www.nejm.org) by Sarah Wakeman, M.D., and Michael Barnett, M.D., establishes the urgency of the problem. "In 2016, there were 42,249 opioid-overdose deaths in the United States," the authors write, noting that this figure represented a 28 percent increase over the previous year. These deaths, they posit, are part of why the National Center for Health Statistics lowered its U.S. life expectancy in 2016 for the second year in a row -- the first such consecutive decline since the 1960s.
- Three articles in the July 5 issue of The New England Journal of Medicine position primary care physicians as key to fighting the opioid epidemic.
- Reducing administrative burdens and incorporating addiction treatment into broader medical training are among the strategies cited.
- Treatment in primary care clinics also could reduce the stigma associated with substance use disorder.
"In part, the overdose crisis is an epidemic of poor access to care," they write. Even as nearly 80 percent of addicted persons receive no treatment, "buprenorphine distribution has been slowing, rather than accelerating to meet demand."
To put medicine in the right hands and curtail overdoses, the authors recommend an in-plain-sight answer: "We believe there's a realistic, scalable solution for reaching the millions of Americans with opioid use disorder: mobilizing the primary care physician (PCP) workforce to offer office-based addiction treatment with buprenorphine, as other countries have done."
This proposal is in line with recent AAFP advocacy efforts.
On June 18, AAFP President Michael Munger, M.D., of Overland Park, Kan., alongside a coalition of other health care leaders, met with lawmakers and their staffs to emphasize key points from joint principals addressing the opioid epidemic(5 page PDF) that the AAFP, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Physicians, the American Osteopathic Association, and the American Psychiatric Association issued together on June 11.
Among the strategies outlined in that document were
- reducing the administrative burdens associated with addiction treatment,
- increasing financial incentives for physicians to treat substance use disorders (SUD), and
- better addressing patient stigma related to SUD.
Wakeman and Barnett center like-minded recommendations on what they say are myths about buprenorphine treatment. When primary care physicians think past these misperceptions, the authors contend, the fight against opioid addiction can move to the primary care physician's office -- and be won.
They argue that buprenorphine isn't a dangerous intervention, despite federal policy that suggests otherwise. Wakeman and Barnett call for regulation to be scaled back, and for buprenorphine training to be included in broader medical education. "All physicians could be trained during medical school and residency, so that both PCPs and other specialists would be equipped to offer this treatment — and, more generally, would be comfortable in caring for patients with opioid use disorder," they write.
The authors also argue that buprenorphine treatment is "no more burdensome than treating other chronic illnesses."
They add: "Moreover, buprenorphine treatment provides one of the rare opportunities in primary care to see dramatic clinical improvement. It's hard to imagine a more satisfying clinical experience than helping a patient escape the cycle of active addiction."
The second article, "Moving Addiction Care to the Mainstream -- Improving the Quality of Buprenorphine Treatment,"(www.nejm.org) by Brendan Saloner, Ph.D.; Kenneth Stoller, M.D.; and G. Caleb Alexander, M.D., says buprenorphine treatment isn't yet "living up to its promise."
Family physicians can play a significant role here, too.
"High-quality buprenorphine treatment can be delivered in primary care and community mental health settings, and is typically straightforward after a patient's condition is stabilized on a maintenance dose," the authors write. "Moreover, providing buprenorphine in primary care settings creates opportunities to concurrently manage other chronic diseases, such as depression and diabetes." (They caution that some cases may still require referral to an opioid treatment program or outpatient clinic.)
The authors of this article, as Wakeman and Barnett also did, emphasize the potential for washing away the stigma of addiction in a primary-care setting: "A national quality strategy could improve the odds of recovery among people with opioid use disorder, normalize their treatment and bring them into the mainstream of medicine -- right where they belong."
The third article complements the buprenorphine discussion by highlighting the potential of a treatment that has been a tough regulatory sell in this country.
"Methadone in Primary Care -- One Small Step for Congress, One Giant Leap for Addiction Treatment,"(www.nejm.org) by Jeffrey Samet, M.D.; Michael Botticelli, M.Ed.; and Monica Bharel, M.D., M.P.H., suggests that rural and suburban communities struggling to combat the addiction crisis may find relief in the medication if primary care physicians are empowered to consider it. Efforts to establish methadone clinics in these areas would encounter hurdles posed by cost and a "not in my backyard" sentiment, the authors point out.
"Allowing physicians to prescribe methadone in primary care settings obviates both of these challenges," they write "What's more, it could reduce the stigma associated with opioid use disorder and place its management more in line with that of other medical conditions that are treated seamlessly in primary care."
The primary barrier in this case is legislative, the authors note.
"We believe the time has come to update laws that regulate the prescription of methadone in primary care in order to reduce barriers to access and extend the benefits of a proven, effective medication to people throughout the country."
Related AAFP News Coverage
AMA Task Force Reports Progress on Reversing Opioid Epidemic