‘Addiction is a chronic medical illness that's treatable,’ and primary care physicians can help

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Primary care physicians could join the front lines of combating the nation’s continuing opioid crisis.

Last year set the stage for potential greater availability of treatment for opioid use disorder (OUD). In January 2023, the U.S. Drug Enforcement Administration (DEA) published guidance stating Congress approved the elimination of the X-Waiver requirement and patient limits, making it easier for primary care physicians to prescribe buprenorphine to more people for OUD treatment.

In fall 2023, The U.S. Agency for Healthcare Research and Quality and the Kaiser Permanente Washington Health Research Institute published new resources positing primary care as a key area for treating OUD. Both said a key step would be greater physician willingness to prescribe buprenorphine.

Brian Hurley, MD, MBA, president of the American Society of Addiction Medicine (ASAM), called it a good start to expanding access to OUD treatment across the U.S. health care system.

Brian Hurley, MD, MBA
_{American Society of Addiction Medicine}

Hurley also is medical director of the Division of Substance Abuse Prevention and Control for the Los Angeles County Department of Public Health.

Medical Economics spoke to Hurley about changes in the law and medicine, and how primary care physicians might save lives in the worst epidemic of drug overdose deaths in American history. This transcript has been edited for length and clarity.

Medical Economics: Can you provide an overview of the current state of addiction treatment and its challenges in the medical field?

Brian Hurley, MD, MBA: We're lucky to live in an era where we have more information about what is effective to treat addiction than ever before. And addiction is treatable through a broad range of medications and counseling and support, and ASAM has a number of practice guidelines that talk about medications for opioid use disorder, medications for other substance use disorders. We just released a clinical practice guideline on the management of stimulant use disorder that highlighted various psychosocial approaches to treating stimulant use disorder. We're lucky that we have a broad set of evidence about what works. One of the challenges is, high-quality addiction care is not yet universally acceptable. Part of that is, we need an addiction-trained workforce to be able to implement the full range of evidence-based practices. And we need all sectors of health care to be participants and identifying and treating addiction. One of the key areas for opportunity is primary care identification of people with substance use disorders, screening and brief intervention, an evidence-based primary care strategy to identify and at the very least have a conversation. And then, for opioid use disorder specifically, there are a number of medications for opioid use disorder that can be feasibly managed in primary care. The most commonly used one of these medications is buprenorphine. One of the key opportunities is to integrate buprenorphine treatment in primary care in a low-threshold way, that is, it doesn't necessarily require patients to take a lot of extra steps as a condition of receiving buprenorphine. Now, one of the things that I hear from my primary care colleagues is, well, we don't have residential treatment on-site, or, we're not running an intensive outpatient program. Primary care practices sometimes have behavioral health clinicians integrated to varying degrees. So, I might hear from my colleagues, but we don't have a full set of behavioral health clinicians integrated into our clinic, so what do we do? And what I would say is, medications for opioid use disorder can be strongly effective on their own and that when patients would benefit from comprehensive psychosocial assessments and connections to a full range of psychosocial services should be based on patient readiness and that primary (care) clinicians can refer people into specialty SUD treatment can connect people to services that they've arranged on site, but that we shouldn't let the availability of the full range of withdrawal management, hospital care, residential care, be a barrier to the initiation of a strongly evidence-based treatment to help reduce overdose risk, to help improve treatment retention, and to really advance and protect the health and wellness of our patients with opioid use disorder.

Medical Economics: By now there have been years of developing public awareness about the opioid crisis and yet national figures show that deaths are not necessarily dropping dramatically. Why is that?

Brian Hurley, MD, MBA: The reason that overdose deaths continue to climb has to do with the composition of our drug supply. At the onset of the most recent overdose epidemic, which really began with prescription opioids – but it's not specific to prescription opioids, that also includes prescription sedatives – we saw a shift. Opioid prescribing has been on the decline in the United States since 2011, so we're not seeing the same rate of prescription opioid overdose that we were seeing much earlier. We saw a shift to heroin, but most recently, we've seen a shift to fentanyl. I live in Los Angeles, fentanyl eclipsed methamphetamine as the number one drug identified in coroner cases. These are fatal overdoses. What we're seeing with the overdose crisis really is a result of the composition of the drug supply, not a result of a lot more people using or failures around the opioid prescribing. That all being said, the supply and utilization of effective treatment for opioid use disorder has also not kept pace. So, what we're seeing is an increasingly toxic drug supply and the remaining tremendous treatment gap with a number – like 80-plus percent of people with opioid use disorders specifically not receiving evidence-based treatment for their opioid use disorder. The combination of fentanyl and other high-potency opioids in our drug supply and, as a health system, us not reliably connecting people with opioid use disorder treatment, is why we haven't been able to keep pace with the overdose fight.

Medical Economics: You mentioned about increasing treatment options across the U.S. health care system, not just primary care. How could that happen or develop? Is there additional awareness needed or regulatory change?

Brian Hurley, MD, MBA: There's no segment of health care that doesn't see patients with addiction right now. Not every sector of health care necessarily holds themselves out as prepared to treat patients’ substance use disorders. Oftentimes we'll hear, oh, I don't know that this is my scope, that this is not what we do in hospital care and specialty care. But I would say in most areas of health care, we have, as close as we can, universal access to the first-line treatments for hypertension, depression, diabetes. Those exist in primary care. And in fact, there are patients in emergency rooms and hospitals and community mental health centers, the street medicine programs, that all get access to first-line treatments for common medical conditions. And addiction is a common medical condition. In recognition of this public health fact, we would say we would want to see first line treatments for addiction be available in hospital settings, its emergency rooms and on medical and surgical wards, and specialty care. I work in a community mental health center myself and I prioritize asking patients around the substances they use and offering treatments that can help support somebody's health and wellness, even if they're not necessarily ready for full, sustained abstinence. There's so much stigma around addiction that I think a lot of the social judgment that we apply related to people in their use of substances can oftentimes get in the way of recognizing that addiction is a chronic medical condition, that it is based in the brain. It's also based on people's life experiences and in the way people develop. And it's treatable, right? It's treatable with medications. It's treated with counseling, it's treatable with support. We don't expect every primary care practice to be setting up a full range of hospital residential intensive outpatient opiate treatment program services. That's not what we expect. But we think that any patient in any setting of care should be able to be asked about the substances, to be able to be started on first-line treatment connected to other resources in accordance with their needs.

Medical Economics: Lawmakers play a role in availability of medicines and money for treatment for opioid use disorder and any number of other conditions. From a policy standpoint, what would you like to see happen next at the national level or at the state level?

Brian Hurley, MD, MBA: ASAM was really happy to see the “X” waiver removed, and mandatory education for all DEA registrants. One of the things we learned from the overdose crisis is we live and work in a country where not every prescribing clinician necessarily understands everything there is to know about unsafe prescribing of controlled substances, and not every clinician feels comfortable treating people with addiction. So, having a DEA mandated set of trainings actually I think is going to be a helpful way to infuse safer prescribing practices, and infuse some of those fundamentals around treating people with addiction in a way that I think will advance advanced care. So, ASAM has been excited about those called the recent policy wins. We still need additional investments in the workforce, we still need more board-certified addiction physicians, we still need more trained addiction professionals. There’s the STAR Loan Repayment Program that goes to repay loans for people that work in addiction settings, that can serve as a foundation of a workforce to make sure people have what they need. And then one additional piece of legislation that we're supporting from a regulatory perspective is the advancement of something called the “Modernizing Opioid Treatment Access Act.” Now this is not actually relevant to primary care directly, although is relevant to board-certified addiction physicians that have primary care practices. But MOTAA is a piece of legislation that would make methadone available through community pharmacies when it is managed by an addiction physician. Right now, the only place to get methadone is either a licensed hospital or a community opiate treatment program (OTP). Ambulatory care practices cannot prescribe methadone for the indication of opioid use disorder, patients have to go to licensed OTPs. That creates a barrier to methadone. But any policy shift with respect to methadone has to balance risks and benefits. Methadone can be a higher-risk medication, say compared to buprenorphine, in terms of its overdose risk. So, ASAM’s position is that board-certified addiction physicians are in a strong position to be able to manage methadone through community pharmacies. And that would be an important step to increase access to methadone, which is a life-saving medication for opioid use disorder, managed by clinicians that we recognize as well-trained in the identification and management of people with addiction. It's not methadone for everybody by anybody, it's a responsible extension of methadone access by clinician experts.

Medical Economics: Our main audience is primary care physicians. What would you like to say to them, or what more would you like them to know?

Brian Hurley, MD, MBA: We're in the worst overdose crisis in American history. And while I want all of my patients to get the full range of meds and counseling and support that’s effective for their addictions, that effective addiction treatment means meeting patients where they are. One thing that every primary care physician can do is to make sure that patients have universal access to Naloxone, any patient who uses any substances or who is friends or family with anyone who uses any substances. Almost every state has good Samaritan laws around Naloxone, so don't ever miss an opportunity to prescribe Naloxone to patients because it can be covered under people's health insurance when prescribed and is a really important tool that can help reverse opioid overdose if it happens. And again, we're the worst overdose crisis in American history, more people are dying of opioid overdose than any point in American history. No one recovers if they've died. We need overdose reversal tools to be universally accessible.

That addiction is a chronic benefit illness and simply meeting with patients and talking about the substance they use, has a positive benefit. There's all research in primary care management of addiction that shows there's a positive result with just two visits where addiction is mentioned, and then a huge improvement in opioid use disorder when medications for opioid use disorder are available. Sometimes I talk to primary care colleagues and they feel overwhelmed – oh, there's so much stuff related to addiction treatment that would be needed, this is well outside of what I can do. But I would say, most of my primary care colleagues talk to patients around their diet and exercise, talk to patients about depression and other mental health conditions. They're not offering a full range of psychiatric hospitals and residential mental health, but they're doing what I call first-line feasible treatments. That's possible with addiction, first-line feasible treatments that can be well incorporated into primary care practice. Addiction is a chronic medical illness that's treatable, and primary care can oftentimes be an essential entry way for people to be able to access effective treatment.