Tuesday, October 3, 2017

Medication-assisted treatment for opioid addiction: the family physician's role

Millions of Americans suffer from a potentially fatal disease that has become so common over the past decade that it has lowered the average life expectancy and has particularly devastated vulnerable populations, such as adults with mental health disorders. Although effective medications exist to treat this national health emergency, only a small fraction of family physicians can prescribe them, and even certified physicians face numerous obstacles to providing treatment where their services were most needed. Instead, efforts have focused on disseminating guidelines to prevent this condition, mostly by reducing known risk factors. Unfortunately, most of what we know about prevention is only supported by low-quality evidence on patient outcomes.

I am writing, of course, about the epidemic of opioid use disorder and overdoses. In an editorial in the Sept. 15 issue of American Family Physician, my fellow editor Dr. Jennifer Middleton argued that while reducing the risk of addiction through the selective and responsible prescribing of opioid medications for pain is important, it is not sufficient to turn the tide. Observing that there is a critical shortage of substance abuse subspecialists, she encouraged family physicians to obtain a Drug Abuse Treatment Act of 2000 (DATA 2000) waiver to prescribe buprenorphine:

Family physicians ... are already adept at combining behavioral interventions with medication management for chronic diseases such as diabetes, cardiovascular disease, and chronic obstructive pulmonary disease; addiction treatment requires a similar combination of lifestyle coaching and prescription oversight. ... 


Buprenorphine is no more complex or difficult to manage than many other treatments routinely used in primary care. Additionally, our specialty has historically embraced the needs of populations labeled as difficult or challenging, such as homeless persons, refugees, and those with developmental disabilities or mental illness. Patients who are struggling with addiction are no less deserving of our attention.

Whether or not medication-assisted treatment (MAT) for opioid use disorder should become part of every family physician's scope of practice is a subject of intense debate, most recently in a pair of Point/Counterpoint editorials in the Annals of Family Medicine. Echoing Dr. Middleton, Dr. David Loxtercamp wrote about his "conversion experience" - the 19 year-old patient with whom he realized that he needed to be able to prescribe MAT to provide adequate care to her and so many others like her. "I am still involved [in MAT]," he wrote, "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. ... Addiction is a chronic disease that is decimating our communities. We need no other reason to embrace its treatment within every primary care practice."

Taking the opposite view that not every family physician can "be at the front lines" of the fight against the opioid epidemic, Dr. Richard Hill outlined several other factors that weigh against most family physicians prescribing MAT: specialized treatment required, comorbid psychiatric illness, methods shortcomings of emerging models of care, and the risk that taking on this additional responsibility would create more job dissatisfaction and burnout. "Even if further research establishes an 'optimal' model of care for use in primary care," he asserted, "the nature of the disease [opioid use disorder] itself will place undue clinical burden on an already overextended clinical workforce. 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."

Both sides of the debate make compelling points. Personally, I am torn. What do you think the family physician's role should be in prescribing MAT for opioid addiction?

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This post first appeared on the AFP Community Blog.

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