Combating chronic pain

July 8, 2020

Understand the tools physicians need to combat chronic pain as the opioid crisis continues.

As the opioid crisis continues, physicians need the most appropriate tools to combat the opioid crisis, including medication-assisted treatment (MAT).

But do they have access to them? And are there enough of these front-line caregivers with the tools they need to help people suffering from an opioid addiction?

Access is a challenge

Medication-assisted treatment, or MAT, involves the use of certain medications, along with counseling and other behavioral therapies to treat addiction. Buprenorphine is one of the three FDA-approved medications used in MAT, according to the Substance Abuse and Mental Health Services Administration (SAMHSA).

Currently, access to this kind of treatment is a challenge for patients across the country, says Mohammad Zare, MD, associate professor and vice chair of community services in the department of family and community medicine at McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth) and the chief of staff of ambulatory care services in the Harris Health System. That includes Houston, where the methadone clinics can’t handle the volume of patients with an opioid use disorder.

In fact, improving access to treatment and recovery services and promoting the use of overdose-reversing drugs are two of the U.S. Department of Health and Human Services’ five top priorities in responding to the ongoing opioid crisis.

But clinicians can’t just prescribe buprenorphine whenever they want to. They must have a special waiver, certifying that they’ve completed a relevant training course.

The federal Drug Addiction Treatment Act of 2000 requires healthcare practitioners to apply for a waiver in order to prescribe or dispense buprenorphine as a treatment for an opioid use disorder. They have to start by conveying their intent to apply for a waiver to the SAMHSA Center for Substance Abuse Treatment.

Currently, physician applicants must provide proof that they’ve completed an eight-hour training course, plus their DEA number and their state medical license number, to be eligible to apply for a first-time waiver.

Zare is the co-site principal investigator of a site in Houston that’s part of the national Primary Care Opioid Disorders  study, a clinical trial designed to examine which strategies can increase buprenorphine prescription rates in primary care settings.

Zare’s team is testing out a collaborative care approach called the Massachusetts Model. They’re comparing one clinic with a clinical nurse manager to support three waiver-trained primary care providers against a control clinic without that additional support. They hope to find out if that support can expand the number of patients they’re able to see and treat in a primary care setting. 

The goal: to find an approach that reaches more people who need MAT so they can experience long-term success. “They become more functional. They go back to work again. They start having a job and going back to their families,” says Zare.

Is the waiver requirement a barrier?

Some suggest that the waiver requirement is a barrier to having more front-line clinicians prepared to provide MAT. But how much of a barrier does the requirement present?

The waiver does set limits on the number of patients for whom a provider can prescribe buprenorphine. But the training course is free, and can be completed at the student’s leisure, notes psychiatrist Michael Mancino, MD, program director of The Psychiatric Research Institute’s Center for Addiction Services and Treatment at the University of Arkansas for Medical Sciences. “That is not a significant barrier,” he says.

Nurse practitioners and physician assistants are eligible for waivers, too. They must complete 24 hours of training, or they can  take the same eight-hour training as physicians, plus an additional 16 hours of training from SAMHSA.

In Arkansas, the number of providers with waivers has grown from 85 to more than 300 over the past few years, according to Mancino. But he says the waiver isn’t the biggest hurdle standing in the way of people gaining access to more waiver-trained clinicians.

“The number one barrier in Arkansas is stigma,” says Mancino.

He explains that some clinicians don’t believe that addiction is an illness-and  thus should not be treated as such. Instead, some still view addiction as a moral failure or the result of a lack of willpower.

Zare agrees that the mindset needs to shift.  “Substance use disorder is a chronic disease,” he says. “We don’t stigmatize someone who has hypertension. We manage it chronically. We need to take patients with substance use disorder and treat them the same way.”

What else is needed?

A recent study in the journal Drug and Alcohol Dependence examined the disparity between opioid overdose deaths and available treatment services in Flint, Michigan. The researchers found that opioid treatment centers were rarely located in the areas where the most overdose deaths occurred.

That’s critical information because it shows where the greatest need lies and illustrates a geographic barrier for people who may want treatment but can’t access it, according to researcher and epidemiologist Debra Furr-Holden, PhD, associate dean for public health integration at Michigan State University and director of the Flint Center for Health Equity Solutions.

The study also illustrates the need for more healthcare professionals who are specialists in addiction medicine, says Furr-Holden.  A generalist with waiver training can be helpful, but having an adequate number of experts with the specialized training and experience is really critical.

“Do you want an orthopedist delivering your baby?” Furr-Holden says. “You want somebody who’s trained. Treating addiction isn’t something that we can just make up as we go along. Our training and medical education needs to catch up to the problem.”

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