Monday, September 19, 2016

Should family doctors treat opioid addiction?

- Jennifer Middleton, MD, MPH

The physicians in the office where I practice recently received the opportunity to train for a Drug Abuse Treatment Act (DATA) waiver for buprenorphine prescribing. A lively discussion among us ensued, with a few of us willing to be trained but the rest uncomfortable with the idea. As I've discussed this issue with others, it seems that many family physicians have strong feelings about not prescribing buprenorphine. The common argument seems to be that these often complex patients should be left to addiction specialists to treat.

Barriers cited in the medical literature to physician prescribing of buprenorphine include a lack of resources, time, and institutional support but also "mistrust of people with addiction...and [a] difficult patient population." 40% of physicians in a 2013 survey believed that buprenorphine diversion contributes to accidental overdoses and is thus dangerous to prescribe.

In the September 1 issue of AFP, though, physicians from the Robert Graham Center argue that family physicians need to be more involved in treating opioid addiction with buprenorphine. They cite a 2014 Cochrane systematic review that demonstrated buprenorphine's efficacy in treating patients with opioid addiction, and they call for policy changes to encourage more family physicians to prescribe buprenorphine. A study in the Annals of Family Medicine found that most physicians with DATA waivers were concentrated in urban areas, leaving 30 million in the U.S. without access to buprenorphine treatment; this same study also found that only 3% of family physicians had DATA waivers as of 2012.

I wrote about current recommendations for opioid use and monitoring a few months ago, and certainly family physicians have an obligation to be responsible regarding opioid prescribing. We have an obligation as a specialty, however, to consider our response to opioid addiction as well. Just under 4000 physicians in the U.S. are board certified by the American Board of Addiction Medicine, which is far insufficient to meet the needs of the estimated 2 million individuals in the U.S. currently struggling with opioid addiction.

The medical literature to date provides little guidance regarding measures to increase buprenorphine prescribing. Providing training in treating addiction during residency increased psychiatry residents' use of buprenorphine in their practices after residency; training Family Medicine residents might be similarly effective. Institutional support and adequate local mental health resources are also likely key. The AAFP recently updated their position paper on chronic pain management and opioid misuse (including a section on buprenorphine use) which includes this call to action:
[T]he AAFP challenges itself and its members at the physician, practice, community, education, and advocacy levels to address the needs of a population struggling with chronic pain and/or opioid dependence.
You can read here about how to obtain a DATA waiver. This 2006 AFP article provides information about initiating and managing buprenorphine treatment, and there's also an AFP By Topic on Substance Abuse.

Are you currently prescribing buprenorphine, or are you considering obtaining a DATA waiver to do so?