Some treatment options for opioid epidemic risk serious unintended consequences

Some treatment options for opioid epidemic risk serious unintended consequences
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Concerns about the current epidemic of opioid- related deaths have focused attention on physician prescribing patterns and deficiencies in the training of the clinical workforce.

Corresponding attention to the lack of access to medications for addiction treatment, primarily buprenorphine and methadone, has generated increased funding for both treatment and post-graduate clinician education and a broad range of new legislative proposals.

One common suggestion has been to eliminate the training requirements for the Drug Enforcement Administration (DEA) buprenorphine waiver, and more recently, calls to change the methadone regulations and permit the prescription of methadone in office-based settings similar that permitted for buprenorphine.


The goal to increase access to evidenced-based treatment is critical — ideally we would like to see every primary care clinician, psychiatrist and all other pertinent specialists become skilled in the treatment of substance use disorders. However, some of the solutions proposed are ill-considered and risk serious unintended consequences.

To effectively resolve this problem it is important to clearly understand the issues that created it. Studies have estimated that between 34 to 56 percent of the physicians trained to use buprenorphine have never prescribed the medication and that among those who do prescribe only 57 percent are at the full capacity of their waiver .

One study estimated that the majority of those who prescribe the medication treat five patients or fewer. Stigma against patients with substance use disorders and prescriber anxiety about managing these clinical problems continue to be major roadblocks to expanding treatment and they will not be resolved by eliminating prescribing restrictions.

Clinician education regarding the treatment of substance use disorders, and in particular opioid use disorder, has been grossly inadequate. Calls for reform in medical school and residency education for both pain management and the treatment of addiction are entirely justified and long overdue. Once these educational changes are implemented, it will still be 4 to 6 years before a better prepared workforce is in place and prepared to practice at the community level.

Eliminating the buprenorphine training and waiver limit requirements and lifting prescribing restrictions on methadone are clear examples of putting the cart before the horse. We lack a trained clinical workforce prepared to use these medications appropriately.

If we were to eliminate training and lift restrictions we run the risk of increased poor quality practice at best and more pills mills at worst. Have legislators forgotten that the opioid epidemic of 1995 was triggered in part by well-intended, but inadequately trained physicians given access to, and aggressively marketed to prescribe, potent opioid pharmaceuticals?

An appropriate response to the worsening epidemic of opioid use disorder and related fatalities must begin with reform to medical school and residency education. Experience to date has shown that education directed to physicians in practice (while clearly necessary) has limited ability to reverse stigma or to generate the number of skilled clinicians needed to contain the epidemic.

Trainees need extensive clinical experience under supervision to acquire the skills necessary to successfully treat these patients. Once that is accomplished, specialized training to utilize buprenorphine and restriction on the use of methadone in office-based practice will be redundant.

Unfortunately it is not feasible to provide this type of training to adequate numbers of physicians currently in practice; the focus of our educational efforts must therefore be expanded to include physicians still in training. Until that is accomplished, any loosening of the current regulations that restrict the use of buprenorphine and methadone could trigger a new expansion of opioid misuse and addiction.

Beyond the necessary focus on physician training it is critical that we build the multidisciplinary infrastructure (both administrative and clinical) needed to support the management of a complex chronic disease such as opioid use disorder. We would not expect that a solo provider could effectively manage complicated disorders such as leukemia or type II diabetes.

Care teams involving physicians, nurses, psychologists, and social workers are becoming the norm in US health care. Why would we expect less when treating a chronic relapsing condition that frequently presents with severe psychiatric and medical complications? The issues described above regarding stigma and lack of the necessary addiction focused education impact the training of all of these other disciplines. Audrey Provenzano made a strong case for the need for a team-based behavioral health system to support addiction treatment in primary care settings.

Fortunately SAMHSA has funded the American Academy of Addiction Psychiatry and a coalition of national professional organizations for the State Targeted Response Technical Assistance initiative to provide prevention, treatment, mentoring and recovery services for the care of opioid use disorder throughout the United States and Territories.

Going beyond provider education, one goal of this initiative is to help each state/territory implement the interventions required to address the infrastructure and multiple systems-level issues necessary to support effective interdisciplinary treatment.

The quick fix of eliminating buprenorphine and/or methadone prescriber requirements is a simple and cheap solution to a complex problem; it will not work and it risks making the problem much worse. Adequate funding is need to support comprehensive educational and consultative initiatives — these efforts are aimed at resolving the problems that have hampered a more effective and robust response to the opioid epidemic and they deserve the support of policy makers.

John A. Renner, Jr. M.D. is a former president of the American Academy of Addiction Psychiatry and a professor of psychiatry at Boston University School of Medicine.