Vermont has a drug problem and doctors have to respond to it. We must prescribe fewer narcotics. Instead of writing prescriptions, we need to start saying, “This will hurt for a few days.” We check VPMS daily, and screen our adolescents for early signs of depression and substance abuse. Yet, only a fraction of Vermont physicians treat addiction to opiates with medications.
In an ideal world, patients would not need these medications, and would find sobriety with detoxification, abstinence and counseling. But, for decades relapse rates remain high regardless of treatment options. For this reason, I believe in risk reduction and a three pronged approach: medication support with buprenorphine, methadone or naltrexone, mental health assessment and frequent counseling, and the removal of environmental cues (or people) that might trigger a relapse. Patients will need a different combination of the above three ingredients for long term sobriety. I believe that patients should be stabilized in a specialty clinic, but once compliant with medication and counseling, they are best treated in the privacy of a family doctor’s office. This is the HUB and SPOKE model and I believe it will work, especially with more spokes.
With MAT (Medication Assisted Treatment) team support, and a close partnership with psychiatric services, I prescribe buprenorphine, Narcan, naltrexone and Vivitrol as part of a regular family medicine practice. I would like to encourage other primary care doctors to include these medicines in your scope of practice, and I have a top ten list of (hopefully) encouraging reasons why you should.
- You are trusted and local. Look around, these patients are your neighbors. They are busy people, balancing kids, work, counseling, and school – just like we are. They want you to prescribe buprenorphine for them because it is more private, closer, less expensive and more comprehensive than going to a HUB treatment center. Many have been on a stable dose for years. Don’t send them over an hour away to another prescriber. Patients are more successful if they can confide in their prescriber, and where there is continuity of care for their other medical concerns.
- The MAT team helps you. The MAT nurse can room patients, witness urine collection, check on counseling compliance, provide accudetox, get prior authorizations for medications, attend Learning Collaborative meetings, do med counts, give Vivitrol injections, even assist in helping a patient find a job or housing. Several small clinics can share a MAT team, and pick days of the week to see patients (we do Tuesdays and Thursdays). This helps standardize care between practices. Finally, if a patient is using drugs but not ready for treatment, the MAT nurse can call in a prescription for Narcan, and be available if the patient calls back needing help getting into the HUB.
- Other mentors will help you. Doctors who prescribe buprenorphine or Vivitrol are accessible and happy to discuss cases or answer questions. This has helped me significantly. The quarterly Blueprint-led Vermont Learning Collaborative brings doctors and MAT teams together and it is an excellent opportunity for a physician new to prescribing to gain a lot of support.
- You can control who you see. Patients are referred to you at the spoke level of care if they are stable and compliant. They are motivated to meet your requirements. If patients have a minor setback, they usually do well with more frequent visits and counseling. In the event of a full relapse, the patient moves to a higher level of care. Since medication is only a small part of the recovery plan, patients must engage in counseling and lifestyle changes to be in your care. Patients need a new phone, new friends, new hangouts, reliable childcare and many appointments with you, counselors and pharmacists. Recovery is a full time job initially.
- Treating addiction reduces stigma. What does “drug addict” mean to you? Addicts break the law, relapse and too often are blamed for their problems. For another chronic medical condition, like obesity or emphysema, the stigma of this illness would never be acceptable. As you get to know patients with addiction, that blame falls away. View opiate addiction like you do other chronic illnesses, and your community will benefit.
- The patients with addiction to opiates are already in your waiting room. They look like all of your other patients: whether they got their first pills from a doctor, a dentist, a friend, or a parent, patients of all ages and backgrounds never expect addiction to take over so quickly. None of them wanted to lie and steal to get their daily fix. None of them understood how bad withdrawal would feel. While they may have chosen to use drugs initially, no one chooses to be an addict. As a patient once told me, “If you wake up in the morning and decide, ‘I am going to get clean today,’ and you call around and can’t find any help, you give up for months”.
- This is not chronic pain. From patients I have learned where to buy drugs, how people use drugs, and what events and emotions lead to their addiction. Patients tell me about the lies they used to feed their doctors, spouses and parents. Since I began prescribing buprenorphine I am much more likely to just say “no” to narcotics for pain in general. I am more likely to reach for non-narcotic medications and therapies. Sometimes injuries hurt, but that is temporary. Why risk addiction forever? For those patients on narcotics, I am also much more likely to suspect diversion than I was before. I feel more comfortable confronting patients whom I suspect, and if there is diversion occurring, I am more likely to refer for treatment instead of just discharging from the clinic. Clinic discharge, the normal practice when there is evidence of abuse, often leads to doctor shopping and more prescriptions, not treatment or sobriety.
- Embrace risk reduction. Buprenorphine has limitations and risks: it can be abused, it can kill, it has street value, and it does not help with addiction to cocaine or alcohol. People may never stop needing it and I accept that. I hope that in the future there will be something better. I agree that abstinence and counseling are great goals, but I recognize that many people cannot take those steps towards sobriety without medications. Have I turned down a young person who wanted buprenorphine? Yes. I am not going to prescribe it until they have proven that an inpatient stay or intensive counseling won’t work. For other patients, especially those with a shorter addiction history, Vivitrol (naltrexone) injections are an even better and safer fit. For each case, we work to find the right medication, the right dose, and the right combination of mental health support. All of this hopefully helps the patient begin to lead a normal life.
- Build this into routine care. Residency in Vermont did not prepare me for this. During a fellowship in Seattle, I was expected to oversee residents in their regular family medicine clinic. Every resident was able to prescribe buprenorphine and I was incompetent to oversee them. I was humbled by their knowledge of addiction, but more impressed that they saw it as a routine part of providing good primary care, like managing diabetes, an ankle sprain, well baby exams or COPD. Let’s integrate addiction medicine into our training programs for the next generation of primary care doctors, and also teach them that even a small pack of pills is NOT needed to leave the ER or office. Too many young addicts report their first taste of narcotic was after they saw a doctor for their wisdom teeth, tonsillectomy, knee sprain or abdominal pain. Don’t handout pills just to get a patients out the door. Instead, teach residents to talk with patients about how to manage pain, non-narcotics options, and how long to expect the pain to last.
- The numbers will climb. I believe that the current opiate epidemic will get worse. Clearly more work is needed in drug use prevention. But, for addiction treatment, we have options – counseling, medications, inpatient, and outpatient programs – just not enough doctors and counselors to do the job. We can no longer expect someone else to do it for us. In March 2016, there were 480 patients on HUB waiting lists, and as Harry Chen MD is quoted saying in 2015, “We’re just scratching the surface. Even if we almost double the number of people in treatment, for each person who seeks it, there are probably 10 others who need it.”
If primary care doctors across the state built MAT into their practice and started with even 5 stable patients, the HUBs could open up space for more acute patients. I believe my ideal panel size in working with a MAT team is about 20-30 patients. But, if more PCPs do NOT take this on, patients in our communities and practices will have to continue to drive to large treatment centers, with depersonalized care, and likely higher opportunity for diversion.
In conclusion, I believe most doctors would find this field of medicine surprisingly enjoyable. To watch a patient transition from lying, stealing and using, to working and parenting over a matter of months is uplifting. I see incredible, rapid, positive changes in my patients; I am more interested and involved in preventing opiate addiction; I am more aware of the concurrent mental health issues that lead to addiction, and I am a much more conscientious prescriber of opiates for chronic pain. Perhaps my experiences will encourage other primary care doctors and residents to follow suit. Frankly, at this point, I believe it is just part of the job.
Katie Marvin, MD, is a family medicine physician at Stowe Family Practice, CHSLV.