Many people in the U.S. have untreated opioid use disorder. Some sources estimate there are as many as three million people in the U.S. with opioid use disorder, and only ten to twenty percent access evidence-based treatment with opioid agonists. This last dismal fact hasn’t changed much over the past twenty years despite governmental initiatives to promote treatment.
In 2023, the requirement for a waiver from the government to prescribe buprenorphine was eliminated, meaning providers no longer had to take an eight- or twenty-four hour training course to prescribe buprenorphine. We all hoped elimination of the waiver would mean more primary care providers would start prescribing buprenorphine.
Why hasn’t this happened? Why don’t more providers – doctors, physician assistants, and nurse practitioners – want to treat patients with opioid use disorders?
I have some ideas:
They don’t know how.
From 1906 until 2000, it was illegal in the U.S. to prescribe an opioid to a patient with addiction with the intent to keep that patient out of withdrawal, even if it stabilized the patient. Doctors went to jail for prescribing opioids to maintain a patient who had developed an addiction. As a result, patients with opioid use disorder, called opioid addicts back then, could not receive care as part of U.S. mainstream medicine. For nearly a century, these patients were excluded from the U.S. healthcare system.
That’s a long time. Attitudes and practices don’t turn around on a dime.
For all that time, most young doctors didn’t learn much about opioid use disorder, or any substance use disorder. It wasn’t part of the job, though doctors spent much time treating the sequalae of substance use disorders.
I went to medical school in the 1980’s, and I learned much about treating cirrhosis, endocarditis, lung cancer, hypertension, atrial fibrillation…all diseases often caused by substances. But I learned little about identifying, treating, or preventing substance use disorders.
When the DATA 2000 Act was passed, doctors had a new option to treat opioid use disorder with buprenorphine, better known under its early trade names as Suboxone and Subutex.
The monumental change of U.S. law allowed by DATA 2000 was met with a giant yawn by mainstream medicine in the U.S. Who could blame them? For decades, mainstream medicine in the U.S. saw substance use disorders as moral failures. Doctors and other providers didn’t know how to treat these issues and preferred patients suffering from these diseases to go elsewhere for help.
Now, more than two decades into our opioid epidemic, we are setting records each year with the number of opioid overdose deaths. Still, the average primary care physician doesn’t know how to use buprenorphine to treat opioid use disorder and has little desire to learn.
Changes in providers’ attitudes are happening, but slowly. Younger practitioners will be better educated than my generation, since medical schools and residencies are training students about opioid use disorder and evidence-based treatments for them.
The DEA now won’t renew a license to prescribe controlled substances until the practitioner completes an eight-hour course on some aspect of substance use disorders. Since DEA licenses must be renewed every three years, and this requirement started in 2023, all providers will get at least this much training by 2026. Will it make a difference? We will see.
They don’t understand who the patients are.
I was talking to my own sweet and well-educated primary care physician. She always asks about my work, and I asked her why she didn’t start treating patients with opioid use disorder. She looked uncomfortable, and said she thought about it, but that she really didn’t want to expose her staff and other patients to that type of patient.
I told her she’s already taking care of these patients, but didn’t know it. They haven’t told her about their opioid use disorder because they’re worried she will judge them harshly, and because they don’t expect help from her with their illness.
I told her those patients were some of the most rewarding I’ve had, because I’ve had the privilege to watch them change and grow out of their addictions and into the people they were meant to be. I told her she was missing out on rewarding experiences.
Readers of this blog know that anyone can become addicted to opioids. This does not make us bad people, just sick people.
Most of my patients are ordinary people. True, I have a few “outlaw” types that I see, but they understand they can’t behave in a way that disturbs me or other patients, and I enjoy seeing them too.
My point is that my doctor didn’t realize patients with opioid use disorder look the same – are the same – as her other patients.
They don’t have time.
I worked as a primary care provider for a total of about ten years. This was a few decades ago but things have only gotten worse since then. Primary care providers are rushed to see more patients in less time. They are asked to cover many topics with their patients. For example, besides any acute illness, the primary care provider is asked to cover preventive health screening. This means talking to patients about getting tests like mammograms, PAP smears, prostate exams, bone density tests, colonoscopies, eye exams and more. Then there’s the list of recommended vaccines. Doctors discuss vaccines for influenza, updated COVID, pneumonia vaccine, shingles, RSV, tetanus, and others. Each vaccine needs a discussion about risks and benefits.
Whew. It makes me tired just thinking about all that.
Primary care providers might ask, “What makes you think I have time to screen for substance use disorders and if I find it, start treatment for it? Can’t you see I’m struggling to get it all done as it is?”
I used to be in that rat race and I don’t think I’d ever want to go back.
They don’t know how well the medication works.
This is big.
I think more primary care providers would prescribe buprenorphine if they knew how much change you can see in the patients for whom it works. Many patients make sudden and lasting life changes when given buprenorphine medication to stabilize their cravings and get rid of withdrawal. We have study after study that shows this medication reduces the risk of dying from an opioid overdose by at least three times. That’s better than almost any other treatment we do in medicine.
Of course, not all patients do well in an office-based setting and some need more intense treatment. They can be referred to opioid treatment programs for more intensive treatment. But most patients change and grow and get their lives back. It’s thrilling to watch them be able to live the life they want without opioids getting in the way. They are the ones doing the hard work of recovery but it’s nice to think maybe I had some small part in their success.
Isn’t that why people go into medicine? We want to make a positive difference. There are no bigger changes in patients than those we treat with substance use disorders.
Primary care providers were burned in the recent past regarding opioids
Several decades ago, well-meaning pain management experts, some of whom were paid by pharmaceutical companies, scolded primary care providers for being “opio-phobic.” By this, these experts meant primary care providers were too afraid to prescribe opioids, in large amounts and long-term. The experts claimed there was less than a 1% chance of a patient developing addiction, but their data was wrong. It wasn’t really even data, just information taken from one letter to a medical journal.
Primary care providers were lead down a primose path toward prescribing opioid more freely, only to learn much later that doing so can harm patients. They likely were kicking themselves for not trusting their own instincts.
Perhaps these providers are more cautious about jumping on board to prescribe buprenorphine, given how they were mislead earlier in this century by pain “experts.”
These reasons I’ve listed based on my own observations are also mentioned in studies of why U.S. medical providers do not prescribe buprenorphine.
I found an article by Huhn et al., from 2017 describing their survey of 558 physicians, most of whom had a waiver to prescribe buprenorphine (not needed after the law changed in 2023).
This study found that the top three reasons for not prescribing buprenorphine were lack of belief in agonist therapy, lack of time, and insufficient reimbursement rates. Not surprisingly, lack of belief in agonist therapy was an opinion endorsed by physicians who did not have a waiver to prescribe buprenorphine.
Most of the physicians already prescribing buprenorphine weren’t prescribing to the maximum allowed number of patients at that time. Most of these physicians cited lack of time and insufficient reimbursement as the main reasons they had not accepted more patients.
So what’s the solution?
Education is key. Showing medical providers the evidence supporting medication to treat opioid use disorder is compelling. Most providers are shocked at the data of how medication to treat opioid use disorder reduces the death rate. If they have a scientific bone in their bodies, they react to this data.
Medications for opioid use disorder also improve the quality of mental and physical health, with reduced suicide rates and reduced criminal activity.
As I said above, the younger generation will learn this data during their training. Older providers will learn it along the way somehow or they will retire without this knowledge.
I don’t have any profound answers how to fix the time crunch issue for primary care providers, and I sure don’t know how to fix the reimbursement issues.
Costs of medical care in the U.S. are rising without a corresponding increase in the quality of that care.
In the U.S. we spend twice as much as other first-world nations per person on healthcare. Most of this money does not go to the doctors, nurses, lab technicians, or other professionals on the front lines. It goes to the increased administrative costs associated with insurance, according to people who know about these things. [1]
Our healthcare system is broken. Fixing this broken system is essential to treating people with substance use disorders.
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