How Primary Care Doctors Can Help Patients Beat Opioid Addiction
General physicians can deliver medication-assisted treatment with help from team members they probably already have in their clinics, a new analysis concludes.
For many of the 2 million Americans addicted to opioids, getting good treatment for their dependence on prescription painkillers or heroin might seem like a far-off dream.
A new study suggests the answer could lie much closer to home, in the primary care clinics where they go for basic medical care.
Evidence compiled by a University of Michigan team suggests that primary care physicians and their teams of nurses, medical assistants, social workers and pharmacists can, beyond providing basic services, also provide effective addiction care.
Their means: the anti-opioid medication buprenorphine and counseling — a combination approach known as medication-assisted treatment, or MAT.
U-M researchers recently published a systematic review of peer-reviewed evidence in PLoS One examining which elements worked well for primary care physicians and clinics that provided MAT. The team hopes its findings will encourage more general practitioners to offer MAT.
Still, the researchers know that making the shift requires extra time and resources.
“It’s hard to convince primary care physicians to do this work when they’re already busy and they don’t have additional addiction-related training or experience,” says Pooja Lagisetty, M.D., M.Sc., the study’s lead author and a U-M primary care doctor who provides MAT to her patients at the VA Ann Arbor Healthcare System.
“But if we can learn from others and find a way to offer physicians logistical support, then maybe it’s possible."
‘Patients are struggling to find help’
MAT has a track record of success for easing withdrawal from opioid dependence — but it requires frequent check-in visits, drug monitoring tests and prescription refills for months or even years after treatment begins.
In addition, the federal government requires that physicians take an eight-hour course before they can prescribe buprenorphine. All of this, Lagisetty says, contributes to an environment in which few primary care physicians provide buprenorphine as addiction treatment.
Still, the practice has increased in recent years, driven by the opioid crisis and MAT coverage through Medicaid expansion in many states.
The government has increased the number of MAT patients that one physician can treat at a time. Nurse practitioners and physician assistants can also get permission to prescribe MAT in states where they have prescribing privileges.
Amid those gains, however, the number of people who need addiction care still far outpaces the number who can provide MAT using buprenorphine — or its more intensive and more restricted cousin, methadone.
Which is why Lagisetty and her team advocate for continued growth.
“I don’t think that many primary care physicians went into medicine with a desire to focus on treating addiction. However, opioid addiction is increasingly becoming common in our practices, and our patients are struggling to find help,” she says.
Encouraging case studies
Lagisetty and her colleagues looked for common elements in successful primary care MAT models around the world. The team compiled data from 41 studies conducted in several U.S. states as well as Great Britain, Australia, Canada, Austria, France, Ireland and Italy.
Collaboration, they found, was a key factor: MAT patients had the highest chance of successful opioid addiction treatment when their primary care physician worked with a team of nonphysicians to deliver MAT.
The successful models featured coordinated care, in which physicians handled the patient encounters where their skills were required or most needed, and other team members helped patients between doctor’s appointments.
Nurse case managers, who handled duties such as check-in phone calls to track patients’ symptoms and cravings, were a common element. A few care models were based solely on a physician handling all MAT duties.
“Multidisciplinary teams were featured in the bulk of the studies we evaluated, though everyone took a different approach — and many ended up with similar results,” says Lagisetty, also a clinical lecturer in the Division of General Internal Medicine at Michigan Medicine, U-M’s academic medical center, and a member of U-M’s Institute for Healthcare Policy and Innovation.
A large majority of the sites included in the studies delivered MAT despite not having a counselor trained in treating addiction.
“This suggests primary care clinics have a bit of wiggle room to use the resources and staff already available at their respective clinics to manage all the components of MAT,” Lagisetty says.
Potential for growth
To make their conclusions, the researchers focused on seven studies that showed the best rates of success — with 60 percent or more of surveyed patients staying on a MAT regimen for three months or more and a good score on the standard scale the U-M authors developed.
Lagisetty notes that many of the clinics in these best studies also didn’t have an addiction psychologist or other addiction counselor as part of their teams. Most, but not all, required patients to sign contracts pledging they would avoid opioids.
The U-M analysis also shows that primary clinics do not need to give the first dose of buprenorphine to patients while they’re in the clinic. Instead, patients can take the first dose safely at home.
These “inductions,” which occur hours after the patient has stopped using opioids and is beginning to feel the symptoms of withdrawal, can occur at home as long as the patient has someone to call about any cravings or symptoms he or she feels after starting the medication.
Lagisetty and her colleagues aren’t the only ones looking at best practices for primary care MAT. She also points to a recent Annals of Internal Medicine scoping review that evaluated the different models for MAT laid out by local and state government agencies.
Primary care teams already provide intensive treatment for other conditions and medication regimens, Lagisetty notes. These range from anticoagulation medicine for people with high risk of blood clots to managing patients with insulin-dependent diabetes or heart failure.
Such patients also often require checks between physician appointments while they are being stabilized. Nonphysician team members help with dose monitoring and frequent check-ins by phone or in person with the patient.
Therein lies the opportunity: “We can build upon these existing resources to similarly treat patients with MAT,” she says.
In fact, Lagisetty and two co-authors on the new paper, Amy Bohnert, Ph.D., M.H.S., and Michele Heisler, M.D., M.P.A., published a paper last year setting forth anticoagulation clinics as a model for MAT. She notes, however, that anticoagulation medications don’t come with the kind of federal regulations that buprenorphine has.
“We already have studies showing that MAT in primary care can produce similar results to providing it in specialty care settings, and patients might be more willing to seek help in a primary care setting because of the lack of stigma and the ability to address their other health concerns,” Lagisetty says. “Doing MAT in primary care makes sense.”
And clinics, she concludes, can start by thinking small: “Primary care doctors don’t need to all be treating 100 MAT patients. It can just be five. We should just have the medication in our toolbox and be able to screen and potentially treat patients in our own setting.”