Medication-Assisted Treatment Should Be Part of Every Family Physician’s Practice: No

Abstract

To read or post commentaries in response to this article, see it online at http://www.AnnFamMed.org/content/15/4/309. Key words: buprenorphine, naloxone drug combination; opioid, opiate substitution therapy; opioid-related disorders; prescribing patterns, physician, primary health careSubmitted September 7, 2016; submitted, revised, March 21, 2017; accepted March 31, 2017. References 1. Lawlor J. Drug overdose deaths in Maine now averaging one a day.Portland Press Herald. November 14, 2016. T he magnitude and tragedy of the national opioid epidemic has prompted The Office of National Drug Control Policy and the US Department of Health and Human Services to prioritize increasing access to medication-assisted treatment. POINT/COUNTERPOINT1,2 The Drug Addiction Treatment Act of 2000 3 enables physicians who complete an 8-hour online course to prescribe schedule III, IV, and V opiates, including buprenorphine/buprenorphine naloxone (B/BN) for opioid use disorders in settings other than outpatient treatment centers such as methadone maintenance clinics. Despite the potential for great expansion, use of B/BN remains limited. [4][5][6] The need to expand the reach of medicationassisted treatment across the country has led many policy makers, academics, and some physicians to suggest that primary care physicians be at the front lines of this effort. While the number and geographic distribution of primary care physicians makes them likely candidates to deliver the care, there are a number of other factors that make this a poor decision for both primary care physicians and patients. ventions including abstinence efforts and Alcoholics Anonymous/Narcotics Anonymous/sponsors, other nonagonist pharmacotherapies, addiction counseling, intensive outpatient treatment, partial hospitalization, residential programs, and other forms of rehabilitation, perhaps even court-ordered treatment with mandatory accountability and urine toxicology screenings. The opioid-dependent patient population being considered for buprenorphine treatment in primary care settings therefore represents a more severe and treatmentresistant population that requires specialist intervention. Just as primary care doctors will routinely treat mild to moderate forms of diabetes and hypertension but will refer the more severely ill patients to endocrinologists or nephrologists for expert consultation and treatment, so too should opiate-dependent patients requiring maintenance with agonists/mixed agonist-antagonists be referred to or seen by specialists in addiction medicine or addiction psychiatry-and not in a primary setting by generalists, or registered nurses with little training on addiction and the use of buprenorphine. SPECIALIZED TREATMENT REQUIRED COMORBID PSYCHIATRIC ILLNESSFurther complicating the care of many opioid-addicted patients is the fact that they are much more likely than the general population to suffer from comorbid psychiatric disorders. In one study 7 it was estimated that co-occurring disorders were quite common: mood disorders (40% t...

Predictors of Medication-Assisted Treatment Initiation for Opioid Use Disorder in an Interdisciplinary Primary Care Model

“…11 Buprenorphine is an alternative to methadone that can be used in primary care, 10 is an effective treatment for OUD compared with abstinence-only treatment models, 10,12,13 and is currently underused. 14,15 Limited research has shown disparities in MAT initiation in primary care settings by age, 14,16 race/ethnicity, 16 and health insurance coverage. 14,16 Findings regarding the relationships between MAT initiation and psychiatric and physical comorbidities are mixed and seem to vary depending on the specific comorbidity.…”

Now is the Time to Address Substance Use Disorders in Primary Care

“…21,22 From our perspective, the primary barrier is the difficulty in obtaining targeted services, due to the limited availability of providers and programs, the reimbursement challenges in paying for such services, and the difficulties patients face in selecting and navigating an array of treatments. For example, one-half of addiction treatment programs do not have a prescriber.…”

Stigma towards opioid use disorder in primary care remain a barrier to integrating software-based measurement based care

“…The research team conducted three focus groups (one per department) in January and February 2020 (prior to the onset of the COVID-19 pandemic). Focus groups were led by one of the authors (FK) and followed a semi-structured guide prepared by two of the authors (AMD, RW) based on a review of prior literature (e.g., [ 6 , 3 , 7 , 19 ], clinical expertise in treating substance use disorders (AMD, RW), and expertise in qualitative data collection and analysis (FK). The guide targeted the following domains: [ 33 ] current practices regarding the diagnosis and management of OUD, [ 25 ] familiarity and opinions regarding OUD treatment options, [ 23 ] positive and negative aspects of offering treatment for OUD in the clinic, and [ 11 ] reactions to proposed method of supporting the diagnosis of OUD and treatment of OUD with computerized clinical decision support.…”