Steven Powell, MD, began treating opioid addiction back in 2009, long before opioids led the news every day. What makes that unusual is that he’s a family practitioner, not a psychiatrist or addiction medicine specialist.
“Nobody expects to be treating [addiction] in a primary care setting,” he said. “Alcoholism and all substance-use disorders are associated with a lot of shame on the part of the patients. It’s not brought up, and doctors don’t go digging for it, so that doesn’t get treated as well as it could.”
Medical science has long recognized addiction as a disease of the brain, not a character flaw. And in 2018, the Texas Medical Association approved new policy stating that “these disorders should be recognized and treated as are all other diseases.” U.S. government policy, mostly the Affordable Care Act, also has pushed for integrating behavioral health, including substance abuse treatment, into primary care.
Nevertheless, “relatively few effective treatments and practices have been widely adopted or faithfully implemented within general medical settings,” according to a 2016 study in the Journal of Substance Abuse Treatment. Some primary care physicians even look down on substance abuse patients in ways they would not a heart or kidney patient, Dr. Powell says. Doctors often fear these patients come with too much emotional baggage to be worth treating.
“That’s absolutely the tragic stereotype,” said Dr. Powell, medical director at CARMAhealth, an Austin-based drug-treatment center. “But people with addiction or substance-use disorder are not, in my experience, any more complicated than a depressed diabetic or an anxious suburbanite. They also are so much more amenable to improvement.”
Moreover, the well-known shortage of all types of physicians is particularly acute in rural areas, especially in psychiatry — the specialty most often engaged with substance-use disorder treatment. (See “Is Psychiatry Cool Again?” November 2018 Texas Medicine, pages 40-43, www.texmed.org/PsychiatryCoolAgain.)
This lack of services poses one of the biggest obstacles to treatment for the more than 2 million Texans estimated to have a substance-use disorder, according to a November 2018 interim report from the Texas House of Representatives Select Committee on Opioids and Substance Abuse. (See “The Cost of Addiction in Texas,” right.)
“Of those who do receive treatment, few receive anything that approximates evidence-based care,” states a 2012 report by the National Center on Addiction and Substance Abuse at Columbia University in New York.
But when primary care physicians like Dr. Powell step in to fill this treatment void, research shows that good things happen. Patients are 50 percent more likely to start treatment and stick with it in a primary care setting rather than an addiction-treatment center, according to a 2017 study by the Commonwealth Fund.
Unfortunately, there are many reasons patients don’t get adequate addiction treatment, says Robert Messing, MD, director of the Waggoner Center for Alcohol & Addiction Research at The University of Texas Dell Medical School in Austin. Most medical schools still don’t train physicians on addiction. Billing and low payment also can be a problem as can, in some cases, lack of additional behavioral health care resources.
Yet for most addiction patients, primary care physicians are “the first line of defense,” Dr. Messing said. “They’re going to see people who have addictions as part of their clientele. So they need to recognize it and at least initiate treatment.”
Trouble with chronic care
Overall, the U.S. health care system isn’t set up to help patients with substance-use problems through the long slog of recovery, says Carlos Tirado, MD, president of the Texas Society of Addiction Medicine and a member of the TMA’s Task Force on Behavioral Health.
“Addiction is a chronic condition marked by periods of relative stability and active phases of illness, relapses,” said Dr. Tirado, an addiction psychiatrist who is founder and chief medical officer at CARMAhealth. “What our treatment system has been set up for — if you can call it a system — is acute care: Individuals who sustain addiction-related injuries or acquire addiction related illnesses.”
Once substance-use patients are out of either drug treatment centers or emergency departments, they often have little contact with medical professionals about treating their disease. This is true for rich patients as well as poor ones, Dr. Tirado says.
“The ability of an individual to be treated by a competent medical professional in their community on an ongoing basis, the same way you treat any other chronic illness, is quite limited,” he said. “There are very few practitioners who identify themselves as addiction-treatment practitioners, and there are very few programs established that are targeted to meeting the chronic care needs of people with addiction problems.”
The opioid epidemic has prompted most medical schools to offer some education on opioids, but only 15 to 20 of the 183 U.S. programs teach addiction as including alcohol, tobacco, and other drugs, according to Kevin Kunz, MD, executive vice president of the American College of Academic Addiction Medicine. Also, the content of this training varies widely, ranging from one lecture to multi-week clinical rotations.
Most of this training is far from comprehensive, Dr. Powell says. (See “Resources for Treating Addiction Through Primary Care,” below.)
The subspecialty of addiction medicine also is relatively new. While addiction psychiatry has been recognized by American Board of Medical Specialties (ABMS) since 1993, addiction medicine for nonpsychiatrists has been recognized by ABMS and the Accreditation Council for Graduate Medical Education only since 2016, according to the American Academy of Addiction Psychiatry.
“There are only 47 addiction training programs in the entire country [and only one in Texas, at Memorial Hermann Medical Group in Houston], so there are a limited number of addictionologists out there,” said Craig Franke, MD, an addiction psychiatrist who serves as chief medical officer at Integral Care, which provides behavioral health care services to Travis County.
Putting new tools to use
However, primary care physicians now have more tools that allow them to treat patients addicted to opioids and alcohol on an outpatient basis, says James Baker, MD, associate chair of clinical integration and services in the department of psychiatry at Dell Medical School and a member of TMA’s Task Force on Behavioral Health.
Methadone, the traditional treatment for opioid addiction, can be prescribed only by certain tightly controlled, federally approved centers. But the newer drug buprenorphine can be prescribed by physicians who take an eight-hour training course and obtain a waiver from the Substance Abuse and Mental Health Services Administration (SAMHSA). Any physician can prescribe naltrexone, which also works for opioids and alcohol addiction, and varenicline, which fights tobacco addiction.
“What’s different now is that primary care physicians now have something to offer as opposed to referring to services that may or may not be available,” Dr. Baker said. “And what they have to offer is the medication-assisted treatment.” (See “TMA Weighs In On Opioid Antagonist Prescriptions,” www.texmed.org/OpioidAntagonistRX.)
The medications, approved by the U.S. Food and Drug Administration, are combined with counseling and behavioral therapies to provide a “whole-patient” approach to treating substance-use disorders. A 2017 study by JAMA Internal Medicine found that patients cared for in this setting had better access to treatment and were less likely to use drugs than those who were referred only to an addiction treatment specialist.
While this type of outpatient care is ideal, in reality many primary care physicians find it difficult to offer behavioral health treatment along with drug treatment, Dr. Powell says. Medical practices often don’t have ready access to behavioral health specialists, especially practices in rural and inner-city areas.
But treatment with just medications can still be extremely effective for a lot of patients, Dr. Powell says, and some research, like a 2016 article in the Journal of Addiction Medicine, indicates behavioral counseling is not always needed.
“That’s not a deal-breaker for me if we can’t get them into a psychiatrist or counselor,” he said. “And a lot of patients just don’t want to go.”
Many addiction specialists, including Dr. Powell, criticize the SAMHSA waiver requirement for buprenorphine, saying it keeps primary care physicians away from opioid treatment.
“We’ve got an epidemic going on,” he said. “We’ve got 50,000 people dying every year [from opioid overdoses], so we want to make [buprenorphine] as available as possible. I don’t have to take a special course to prescribe [opioids like] oxycontin.”
The 2018 U.S. Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act provides more resources to fight opioid addiction and expands treatment options.
The new law does not address the buprenorphine waiver or billing problems, such as difficulties obtaining prior authorization for some medications and treatments. But it does create an alternative payment model for Medicare patients that improves access to medications for patients needing opioid treatment and authorizes grants for states to improve prescription drug monitoring programs.
Just as important, the law expands the availability of telehealth services for Medicare and Medicaid substance-use disorder treatment, and improves Medicare payment for telehealth programs. It also promotes Project ECHO, an innovative program in which specialists can train primary care physicians in other locations via teleconference. (See “ECHO-ing Across Texas,” February 2019 Texas Medicine, pages 44-46, www.texmed.org/ECHO.)
Naturally, treating people with substance-use disorders has its frustrations, Dr. Powell says. Relapses and other disappointments are part of the practice. But he’s seen a gradual increase in the number of primary care physicians treating addiction and he’s confident that, like HIV treatment before it, addiction treatment will become more mainstream over time.
Helping people fight addiction reminds him of why he became a physician.
“You start treating this person with substance-use disorder — especially opioids — with buprenorphine [or other drugs], and you watch them flourish,” he said. “They can hold down a job. They can be a good spouse and a good parent and a good son or daughter. They’re participating in their friend group again. You change their lives.”
Tex Med. 2019;115(3):40-43
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