Volume 4, Issue 3

Regarding Substance Using Patients and Buprenorphine: A Primary Healthcare Challenge
Steve Martino, PhD
Ismene Petrakis, M.D.
Yale University School of Medicine

Acknowledgments: Steve Martino and Ismene Petrakis are supported by the following: Veterans Affairs Connecticut Healthcare System, the Department of Veterans Affairs New England Mental Illness Research, Education, and Clinical Center (MIRECC), with additional support provided by the US National Institute on Drug Abuse grants (DA027194, DA034243). The views expressed in this article are those of the authors and do not represent the views of the VA or NIDA.

Dr. Junig presents a frank assessment of the multiple regulatory and political factors that have impeded greater utilization of buprenorphine for the treatment of opiate addiction. He suggests that by (1) eliminating the patient cap of 100 per certified physician, (2) trusting physicians to make their own counseling decisions about how they support buprenorphine treatment, (3) increasing insurance coverage for indefinite maintenance, and (4) asking physicians to follow scientific findings and fight regulations not based on them, many more physicians would treat opiate addicted patients with buprenorphine. Dr. Junig’s points are well taken and underscore the complex array of provider authorities, regulatory constraints, and philosophical contentions that affect the implementation of buprenorphine treatment in the United States.

In addition to the factors discussed by Dr. Junig, we would like to highlight an additional avenue for improving buprenorphine implementation: reducing the negative regard many physicians and other healthcare providers have toward patients with substance use disorders. Gilchrist et al. (2011) found that a mixed group of healthcare professionals had considerably more negative attitudes toward patients with substance use disorders compared to patients with other medical diagnoses and that their regard for these patients was poorer than that held by their colleagues in general psychiatry or in specialty addiction services. Likewise, van Boekel et al. (2014) extended these findings, demonstrating the poorer regard general medical physicians, in comparison to professionals working in psychiatry and addiction services, held toward by patients who abused alcohol or drugs.

In particular, physicians were more likely to see addiction as a consequence of the patients’ weakness and to pity those they treated. In general, the stigmatization of patients with substance use disorders by healthcare providers has been a longstanding problem (Abouyanni et al., 2000; Berger, Wagner, & Baker, 2005; Chappel, Veach, & Krug, 1985; Fortney et al., 2004). Historically, this stigmatization has been greatest for patients addicted to narcotics (Campbell and Lovell, 2012). With this as a mindset, who would want to treat these patients, let alone prescribe them buprenorphine?

Healthcare providers’ poor regard for patients with substance use disorders risks many negative consequences. It can lead to lower quality of healthcare, poor patient treatment adherence, and less patient utilization of substance use interventions (Bitarello et al, 2012; Fortney et al., 2004; Kahan et al., 2004). It may heighten the degree to which healthcare providers hold patients personally responsible for their addictive behaviors and limit provider willingness to offer these patients assistance (Corrigan et al., 2005). Furthermore, patients may internalize providers’ negative beliefs as true about themselves (Ronzani, Higgins-Biddle, and Furtado, 2009). The under-utilization of buprenorphine may be yet another negative consequence of the ongoing poor regard many healthcare providers have for patients with substance use disorders.

In this context, efforts to implement all medication-assisted treatments for substance use disorders, including buprenorphine, have been difficult. For example, naltrexone was established as an FDA-approved pharmacotherapy for alcoholism in 1994, yet the uptake of this treatment in practice has been slow at best (Abraham, Rieckmann, McNulty, Kovas, & Roman, 2011). We are less optimistic than Dr. Junig that the number of physicians who prescribe buprenorphine would significantly increase or that this efficacious treatment would become more available to patients if regulatory constraints were lessened.

Efforts to remove misguided regulatory controls must be matched with equally strong efforts to educate and train healthcare providers to have more positive regard for patients with substance use disorders and to encourage more of them to specialize in the addiction treatment field. Fundamentally, healthcare professionals need to feel the work with this patient group is legitimate.

There is room for optimism about the possibility of reducing the negative regard some healthcare professionals have toward patients with substance use disorders. Evidence suggests that increasing exposure to buprenorphine treatment may lead to greater uptake of it. Knudsen, Abraham, Johnson, and Roman (2009) found that community treatment programs that had participated in buprenorphine treatment research studies within the NIDA Clinical Trials Network doubled in-house buprenorphine treatment over the course of two years, controlling for level of care and for-profit status. As physicians become increasingly exposed to the benefits of buprenorphine treatment and staff positively disposed toward it, they may adopt more positive attitudes toward buprenorphine and see the use of it as falling within their scope of practice. In addition, determined, well-organized educational efforts may help change providers’ philosophies and practices. The NIDA and SAMHSA/CSAT Blending Initiative has provided several products designed to heighten awareness about buprenorphine treatment, dispel general myths about medication-assisted treatment, and inform providers about how to conduct short-term opioid withdrawal using buprenorphine and the benefits of using buprenorphine with young adults (Ling et al., 2010). These educational products might help promote physicians’ use of buprenorphine treatment.

Moreover, psychiatrists are getting added qualifications in addiction psychiatry, a subspecialty accredited by the Accreditation Council for Graduate Medical Education (ACGME) since 1997. At the outset, there were only 13 addiction psychiatry programs; this has grown to approximately 46 (see http://www.acgme.org/ads/Public/Reports/ReportRun?ReportId=1&CurrentYear=2013&SpecialtyId=87). Further, initiatives such as one taken by the American Academy in Addiction Psychiatry (AAAP), initiated training for prescribing buprenorphine during residency training, thereby reaching a broader group of psychiatrists, not all of whom became trained in addiction. In addition, concerted effort is being put into increasing the number of physicians, focusing primarily on primary care, who obtain a subspecialty in addiction medicine. The American Board of Addiction Medicine (ABAM) now accredits 19 fellowship programs to train physicians in addiction medicine. The programs have resulted in over 3000 physicians being certified in addiction medicine by ABAM (see http://www.abamfoundation.org/accredited-residencies-in-addiction-medicine/). We need more ABAM-supported addiction fellowship programs to build a physician workforce that has the requisite knowledge to treat patients who have substance use disorders, including using buprenorphine as part of their treatment armamentarium.

Likewise, the American Society of Addiction Medicine (ASAM) promotes physicians’ education and training in the care of patients with substance use disorders. ASAM provides educational resources, online learning, and live courses to help physicians develop expertise in addiction medicine, as well as to maintain their ABAM certification. ASAM provides a professional home for like-minded physicians to share resources and expertise and to train one another in a myriad of addiction topics, such as the use of buprenorphine. Finally, the Veterans Administration (VA) recently launched the Inter-professional Addiction Treatment Advanced Fellowship Program. This fellowship provides two years of post-residency, post-doctoral research, education, and clinical training to physicians and allied healthcare professionals in advanced addiction care. Graduates are expected to become leaders in the field.
Increasing the implementation of buprenorphine treatment must occur in a healthcare context that has a more positive regard toward treating substance using patients. As more healthcare providers recognize substance use disorders as chronic health conditions that fall within their scope of practice, then they might become more open to using the array of medication-assisted therapies available to treat patient who struggle with addiction. Lessening the continued stigmatization of substance using patients through education and training of healthcare providers remains a primary healthcare challenge.

References

Abouyanni, G, Stevens, L.J., Harris, M.F., Wickes, W.A., Ramakrishna, S.S., Ta, E., et al. (2000). GP attitudes to managing drug- and alcohol-dependent patients: a reluctant role. Drug and Alcohol Review, 19, 165-170.

Abraham, A.J., Rieckmann, T., McNulty, T., Kovas, A.E., & Roman, P.M. (2011). Counselor attitudes toward the use of naltrexone in substance abuse treatment: A multi-level modeling approach. Addictive Behaviors, 36, 576-583.

Berger, M., Wagner, T.H., & Baker, L.C. (2005). Internet use and stigmatized illness. Social Sciences & Medicine, 61, 1821-1827.

Bitarello do Amaral-Sabadini, M., Cheng, D.M., Lloyd-Travaglini, C., et al. (2102). Is a patient’s type of substance dependence (alcohol, drug or both) associated with the quality of primary care they receive? Quality in Primary Care, 20, 391-9.

Campbell, N.C. & Lovell, A.M. (2012). The history of the development of buprenorphine as an addiction therapeutic. Annals of the New York Academy of Sciences, 1248, 124-139.

Chappel, J.N., Veach, T.L., & Krug, R.S. (1985). The substance abuse attitude survey: An instrument for measuring attitudes. Journal of Studies on Alcohol, 46, 48-52.

Corrigan, P.W., Lurie, B.D., Goldman, H.H., Slopen, N., Medasani, K., & Phelan, S. (2005). How adolescents perceive the stigma of mental illness and alcohol abuse. Psychiatric Services, 56, 544-550.

Fortney, J., Mukherjee, S., Curran, G., Fortney, S., Han, X., & Booth, B.M. (2004). Factors associated with perceived stigma for alcohol use and treatment among at-risk drinkers. Journal of Behavioral Health & Service Research, 31, 418-429.

Gilchrist, G., Moskalewicz, J., Slezakova, S., Okruhlica, L., Torrens, M., Vajd, R., & Baldacchino, A. (2011). Staff regard towards working with substance users: A European multi-centre study. Addiction, 106, 114-1125.

Kahan, M., Wilson, L., Liu, E., Borsoi, D., Brewster, J.M., Sobell, L.C. et al. (2004). Family medicine residents’ beliefs, attitudes and performance with problem drinkers: A survey and simulated patient study. Substance Abuse, 25, 43-51.

Knudsen, H.K., Abraham, A.J., Johnson, J.A., & Roman, P.M. (2009). Buprenorphine adoption in the National Drug Abuse Treatment Clinical Trials Network. Journal of Substance Abuse Treatment, 37, 307-312.

Ling, W., Jacos, P., Hillhouse, M., Hasson, A., Thomas, C., Freese, T., et al. (2010). From research to the real world: Buprenorphine in the decade of the Clinical Trials Network. Journal of Substance Abuse Treatment, 38 (Suppl 1), S53-S60.

Ronzani, T.M., Higgins-Biddle, J.H., & Furtado, E.F. (2009). Stigmatization of alcohol and other drug users by primary care providers in Brazil. Social Sciences & Medicine, 69, 1080-1084.

Van Boekel, L.C., Brouwers, E.P.M., Van Weeghel, J., & Garretsen, H. F.L. (2014). Healthcare professionals’ regard towards working with patients with substance use disorders: Comparison of primary care, general psychiatry and specialist addiction services. Drug and Alcohol Dependence, 134, 92-98.



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