“One of the Most Rewarding Things I Do”: Bringing Addiction Care into the Community

By Lucy Berrington, MS, Vital Signs editor

The opioid-related death toll is pushing the medical and public health professions to demystify addiction treatment and build capacity for treating substance use disorders within communities across Massachusetts.

One in 25 people in the Commonwealth has an opioid use disorder (OUD), according to data from the Massachusetts Department of Public Health. Strong evidence supports treating OUD with medication as a means to save lives and restore functioning in people who use drugs. “Patients with OUD who are dying — I can turn their life around with a medication within days,” says Daniel P. Alford, MD, MPH, who directs the Clinical Addiction Research and Education Unit at Boston Medical Center and the Safe and Competent Opioid Prescribing Education Program at Boston University School of Medicine.

Prescribing medication treatments benefits him, too: “Buprenorphine treatment is one of the most rewarding things I do in primary care. There are not many things I do that make people feel better right away.” That message may surprise overburdened practitioners. “I think people have this idea that addiction treatment is going to be hard and not satisfying, and it couldn’t be further from that,” says Sarah E. Wakeman, MD, medical director of the Substance Use Disorders Initiative at Massachusetts General Hospital (MGH). “Watching patients’ transformation is really rewarding, and that’s something we don’t talk enough about.”

Lowering Barriers to Care

The opioid crisis, combined with a patient-centered approach to medicine, has highlighted systemic barriers to effective addiction care. “We talk about people not being ‘ready’ for treatment, but often we’ve built treatment models that are unwelcoming,” says Dr. Wakeman, who is an assistant professor of medicine at Harvard Medical School. “People don’t fail treatment, but treatment models can fail people.”

Addiction care has traditionally been underplayed in medical training and fragmented from much of medical practice. Patients hospitalized for acute complications of substance use disorder (SUD) typically received little or no support addressing the disorder itself, says Dr. Wakeman. While substance use disorders including OUD undoubtedly affect the existing patient populations of primary care practices across the state, physicians may not feel they have the means to treat addictions in-house.

That may reflect in part providers’ misperceptions about SUDs. “Addictions are a complex disorder,” says Luis Sanchez, MD, an addiction psychiatrist and a member of the MMS task force on opioids. “You have to be willing to stay with patients for a long time. You have to accept it’s a relapsing disorder. But it’s also extremely treatable, and people do get well.”

Treating Opioid Addiction

Three evidence-based medications are available to treat OUD. Methadone is a Schedule II full opioid agonist offered only at licensed methadone clinics. Naltrexone, an opioid antagonist, can work for highly-motivated patients, though may precipitate withdrawal in people who are actively using opioids, and its long-acting injectable form (Vivitrol) can be “cumbersome to prescribe,” says Dr. Alford, who is a professor of medicine at Boston University School of Medicine. The barriers to prescribing are generally lowest for buprenorphine, which as a partial opioid agonist (Schedule III) has a substantially lower risk of overdose than methadone. Buprenorphine reduces the risk of overdose death in people with OUD by more than 50 percent, research shows.

The most common route to becoming qualified to prescribe buprenorphine is an eight-hour live or online training with a qualifying organization, such as the American Society of Addiction Medicine, which issues waivers to participants. Prescribing buprenorphine is straightforward, yet up to half of the clinicians who get waivered do not go on to treat patients with this medication. “The training is very detailed and covers every imaginable situation — withdrawal, pregnancy, relapse prevention, and so on. It has a tendency to scare people off,” says Dr. Sanchez. Part of the present challenge, then, is connecting physicians with mentoring and further support.

Team-Based Care

Making specialist support available to primary care providers improves clinical practice, Dr. Wakeman says. In October 2014, MGH launched a system-wide redesign of addiction care, encouraged by the positive outcomes of research completed by colleagues at Boston Medical Center. The program incorporated addiction treatment into hospital care and connected addiction consultants with primary care practitioners. “We are not necessarily asking physicians to open their practices to this new patient population,” says Dr. Wakeman. “We just want to equip them to care for the patients they already have. Providing effective primary care to someone with untreated OUD is very challenging.”

Surveys of general internists at MGH suggest that simply having a patient receive care via the redesigned model has generated positive changes in the physicians’ attitudes, preparedness, and clinical practice related to SUD, including greater willingness to prescribe medications for addiction (Journal of Addiction Medicine, 2017). Any physicians can access national and state resources for building their addiction treatment capacity.

Destigmatizing Treatment

A bitter reality for people with OUD is that while their condition is stigmatized, so is its most effective treatment. The notion that treatment with methadone or buprenorphine is not a “legitimate” form of recovery still lingers in communities, legislative chambers, and even some medical practices. “Patients are quick to pick up on physicians’ judgment,” says Dr. Sanchez. “A patient told me a PCP said to him, ‘Methadone’s a bad medication; why are you on it?’ It’s about providers’ naiveté, not wanting to take the time to understand how methadone works.”

“The term medication-assisted treatment is itself stigmatizing and is falling out of favor: We don’t call insulin medication-assisted treatment,” says Dr. Alford. Medication treatments for OUD are not “less than,” he says — if anything, they are “more than.” “This is medication plus.” Medication brings to an end the highs, withdrawals, and neurological changes associated with street drugs of unknown provenance and composition. On medication, physiology stabilizes; brain-imaging studies show the normalization of patients’ neurochemistry, says Dr. Alford. And when patients are no longer living in fear of withdrawal, they return to school, become employed, or access other forms of treatment, such as counseling.

“We’re talking about people who are seeking treatment,” says Dr. Alford. “They’re coming to you saying, ‘I want help, I need help.’ You have the ability to become qualified to offer a medication to save this person’s life, and often it’s a young person.”