What Role Should Psychiatrists Have in Responding to the Opioid Epidemic?

Abstract

The current opioid epidemic has spread rapidly through the United States, resulting in an exponential increase in opioid-associated deaths, transmission of infectious diseases, and a social crisis, which includes a sharp increase in the number of children in foster care because of parental neglect, incapacity, and/or overdose. To stem this tide, public health initiatives must address the treatment needs of more than 11 million people aged 12 years and older who misuse opioids, including the shortage of practitioners to treat those with opioid use disorder (OUD). 1,2 Currently, there are 3 highly effective medicationassisted treatments for OUD: the μ-opioid receptor agonist methadone, the antagonist naltrexone (in oral and long-acting injectable forms), and the partial agonist buprenorphine (used mainly as combination buprenorphinenaloxone). Methadone must be dispensed in a federally licensed facility, and therefore access is limited. Naltrexone requires detoxification prior to initiation, while treatment with buprenorphine can be provided without detoxification in an office-based setting. Thus, buprenorphine provides a means to rapidly expand treatment capacity. Treatment with buprenorphine has been shown to decrease illicitopioiduse,overdosedeaths,HIVandhepatitisCtransmission,andcriminalbehaviorandimprovesocialfunctioning in individuals with OUD. 1 A national movement to train physicians to provide treatment with buprenorphine, particularly among primary care physicians, has resulted in a significant increase in buprenorphine prescribing by this group. With the shift to prescribing in primary care settings, the relative percentage of prescriptions prescribed by psychiatrists declined from 92.2% in 2003 to 32.8% by 2013. 3 The increased prescribing of buprenorphine by primary care physicians is a welcome development because treatment of OUD should be shared among physicians across all specialties. However, we believe psychiatrists could do more in response to this public health crisis. General psychiatrists do not routinely incorporate addiction treatment in their practice, and a national survey of psychiatrists indicates that more than 80% were uncomfortable with providing office-based opioid treatment. 4 We believe psychiatrists are uniquely skilled and ideally suited to be leaders in treating this epidemic. Psychiatry as a field was the first to recognize the need for training in addiction within graduate medical education. In addition, psychiatrists are knowledgeable about neurobiology and psychological principles underlying behavior and the treatment of behavioral disorders. Moreover, the treatment of OUD is often complicated by the high prevalence of comorbid psychiatric disorders, which also influence adherence to buprenorphine treatment. 5

Trends in Buprenorphine Prescribing for Opioid Use Disorder by Psychiatrists in the US From 2003 to 2021

“… 1 , 2 Given the high rate of psychiatric comorbidities among patients with OUD (60%), 3 psychiatrists are uniquely positioned to provide high-quality integrated care for this population. 4 In the 2010s, however, there were large shifts in buprenorphine prescribing to primary care physicians, physician assistants (PAs), and advanced practice registered nurses (APRNs), 2 and it is not known how buprenorphine prescribing by psychiatrists has changed since then. This study therefore compared national trends in patients treated with buprenorphine by psychiatrists and nonpsychiatrists from 2003 to 2021.…”

Why Integrating Medications and Psychosocial Interventions is Important to Successfully Address the Opioid Crisis in Canada

“…We argue this is only possible by taking a holistic approach, which combines pharmacotherapies, PSIs and social supports. The role of psychiatrists, or prescribing clinicians skilled in mental health and addictions care, in helping to achieve this integration is of paramount importance, 7 and such training should begin at the level of medical students and residents.…”

Been There, Done That: Lessons from Vancouver’s Efforts to Stem the Tide of Overdose Deaths

“…Finally, beyond the empirical evidence, other experts in the field have reflected on the importance of addiction psychiatry with similar arguments. 9,10 Switzerland is a great example of how quality care and interdisciplinary collaboration can change the whole situation, with a coverage of substitution treatment between 70% and 75% and a retention in care for the first year in the same range because of a number of medication options including heroin-assisted treatment and excellent psychosocial care. 11 There are just no waiting times to see a psychiatrist or counselor in Basel or Zurich.…”