New England Journal of Medicine – Despite widespread awareness of the opioid-overdose crisis, the epidemic continues to worsen. In 2016, there were 42,249 opioid-overdose deaths in the United States, a 28% increase from the previous year. According to the National Center for Health Statistics, life expectancy in the United States dropped in 2016 for the second consecutive year, partly because of an increase in deaths from unintentional injuries, including overdoses. It was the first 2-year decline since the 1960s. How can we be making so little progress?
Annual Change in Buprenorphine and Methadone Volume Dispensed in the United States, 2006–2016.
In part, the overdose crisis is an epidemic of poor access to care. One of the tragic ironies is that with well-established medical treatment, opioid use disorder can have an excellent prognosis. Decades of research have demonstrated the efficacy of medications such as methadone and buprenorphine in improving remission rates and reducing both medical complications and the likelihood of overdose death.1 Unfortunately, treatment capacity is lacking: nearly 80% of Americans with opioid use disorder don’t receive treatment.2 Although access to office-based addiction treatment has increased since federal approval of buprenorphine, data from the Drug Enforcement Administration (DEA) reveal that annual growth in buprenorphine distribution has been slowing, rather than accelerating to meet demand (see graph). To have any hope of stemming the overdose tide, we have to make it easier to obtain buprenorphine than to get heroin and fentanyl.
We believe there’s a realistic, scalable solution for reaching the millions of Americans with opioid use disorder: mobilizing the primary care physician (PCP) workforce to offer office-based addiction treatment with buprenorphine, as other countries have done. As of 2017, according to the Kaiser Family Foundation, there were more than 320,000 PCPs, plus a broad workforce of nurse practitioners and physician assistants, treating U.S. adults. In contrast, there are just over 3000 diplomates of the American Board of Addiction Medicine, and only 16% of 52,000 active psychiatrists had a waiver to prescribe buprenorphine in 2015 (moreover, 60% of U.S. counties have no psychiatrists).3 Training enough addiction medicine or psychiatric specialists would take years, and most methadone treatment programs are already operating at 80% of capacity or greater.4
However, PCPs and other generalists, including pediatricians, obstetrician–gynecologists, and physicians who treat human immunodeficiency virus (HIV) infection, are well situated to provide buprenorphine treatment. Many have risen to this challenge: PCPs are responsible for most ambulatory care visits for buprenorphine treatment. The importance of mobilizing the PCP workforce while ensuring the availability of sufficient specialists is not unique to the opioid-overdose crisis. During the height of the HIV/AIDS epidemic, for example, access to antiretroviral therapy was urgently needed. Although initially specialists were more likely to prescribe antiretrovirals, by 1990 equal percentages of patients were receiving antiretroviral therapy from PCPs and from specialists.
Myths and Realities of Opioid Use Disorder Treatment.
How can we promote adoption of buprenorphine treatment by PCPs? The relevant federal and state regulatory barriers could be addressed, but they reflect a deeper problem: stigma and myths about buprenorphine treatment inhibit its acceptance (see table).
The first myth is that buprenorphine is more dangerous than other interventions physicians master during training. In fact, PCPs regularly prescribe more complicated and risky treatments. Titrating insulin, starting anticoagulants, and prescribing full-agonist opioids for pain are often more challenging and potentially harmful than prescribing buprenorphine. Yet this perception has been cemented by federal policy. The Drug Addiction Treatment Act of 2000 requires that physicians complete 8 hours of training (sacrificing a full day of work) and apply for a DEA waiver to begin prescribing buprenorphine. After passing these hurdles, physicians are authorized to treat only a limited number of patients. These requirements make buprenorphine treatment intimidating.
The first step toward debunking this myth would be to scale back these federal regulations. Training in appropriate buprenorphine treatment optimizes outcomes and minimizes risks, but such training could be incorporated into existing medical education. All physicians could be trained during medical school and residency, so that both PCPs and other specialists would be equipped to offer this treatment — and, more generally, would be comfortable in caring for patients with opioid use disorder.
The second myth is that buprenorphine is simply a “replacement” and that patients become “addicted” to it — a belief still held by some physicians. But addiction is defined not by physiological dependence but by compulsive use of a drug despite harm. If relying on a daily medication to maintain health were addiction, then most patients with chronic health conditions such as diabetes or asthma would be considered addicted.
A closely related myth is that abstinence-based treatment, usually implying short-term detoxification and rehabilitation, is more effective than medication for addiction treatment. This belief underpins widespread advocacy for more substance use treatment “beds” as a key solution for the overdose crisis. But whereas there’s a strong evidence base for buprenorphine and methadone treatment, no study has shown that detoxification or 30-day rehabilitation programs are effective at treating opioid use disorder.5 In fact, these interventions may increase the likelihood of overdose death by eliminating the tolerance that a patient had built up. To address myths about the effectiveness of buprenorphine and abstinence treatment, we can start with advocacy and education about the evidence to counter misleading depictions of addiction treatment in the media.
Another myth is that providing buprenorphine treatment is particularly onerous and time consuming. In our experience, it is no more burdensome than treating other chronic illnesses. A typical visit includes assessing medication adherence, examining disease control (e.g., cravings and use), titrating doses, and ordering laboratory tests. Moreover, buprenorphine treatment provides one of the rare opportunities in primary care to see dramatic clinical improvement: it’s hard to imagine a more satisfying clinical experience than helping a patient escape the cycle of active addiction. The fact that, for in-office inductions, patients must wait until withdrawal begins to take an initial buprenorphine dose under observation undoubtedly contributes to fears about the demand on physicians’ time. But this process has not been shown to be more effective than having patients start the medication outside the office. In fact, buprenorphine management provided by a PCP is effective with or without additional psychosocial interventions. This myth could be countered by developing and disseminating protocols emphasizing home induction and primary care models for treatment, including approaches consistent with efforts to transform practices into patient-centered medical homes.
Finally, some observers believe that physicians should simply stop prescribing so many opioids. The crisis began with increased opioid prescribing, yet as prescribing rates have fallen since 2011, overdose deaths have accelerated. If prescribing patterns were the sole driver of overdoses, then decreased prescribing should have had a measurable effect on opioid-related mortality over the past several years. In reality, research has demonstrated that interventions like the introduction of abuse-deterrent Oxycontin, which reduce access to frequently misused prescription opioids, have resulted in people shifting their opioid of choice predominantly to heroin. Rising overdose mortality despite decreasing opioid prescribing suggests that merely reducing the prescription-opioid supply will have little positive short-term impact. Reducing prescribing could even increase the death toll as people with opioid use disorder or untreated pain shift into the unstable, illicit drug market. Instead, we need safer, more thoughtful opioid prescribing and accessible support, such as electronic consultations with addiction specialists, to help physicians offer buprenorphine for people with opioid use disorder.
We are in the midst of a historic public health crisis that demands action from every physician. Without dramatic intervention, life expectancy in the United States will continue to decline. Mobilizing the PCP workforce to offer office-based buprenorphine treatment is a plausible, practical, and scalable intervention that could be implemented immediately. The opioid-overdose epidemic is complex and will require concerted efforts on multiple fronts, but few other evidence-based actions would have such an immediate lifesaving effect. It won’t be easy, but we are confident that U.S. PCPs have the clinical skill and grit to take on this challenge.