Primary Care Physicians Bench Themselves in Battle Over Opioid Crisis

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Until the 2000 passage of the Drug Abuse Treatment Act, the American medical system largely treated those with substance abuse disorders by encouraging abstinence and directing patients to treatment centers, mental health counselors, or 12-step programs like Narcotics Anonymous. Some medical schools — particularly those in urban settings — train students on addiction management, but many only offer cursory guidance on such issues.Among other measures, the legislation made it possible for more clinicians to treat patients with buprenorphine, one of the few opioid addiction treatments approved by the Food and Drug Administration.

Buprenorphine, most commonly known by the brand name Suboxone, is an opium derivative that produces a normalizing effect on the brains of people who are addicted to opioids. In proper doses, the treatment allows patients to carry out their normal daily activities, while blunting cravings for opioids. It also can block the effects of drugs like heroin and methadone.

But buprenorphine is just one part of addiction management.

The eight-hour certification course currently offered to clinicians seeking to treat opioid use disorders includes four hours of online training and four hours of live instruction. That, experts say, is not enough time to give primary doctors any semblance of confidence that they can manage the psychosocial complexities of patients with opioid use disorders.

In addition to writing a prescription for buprenorphine, for instance, doctors must understand how to approach patients who commonly suffer from cognitive impairments and mental health pathologies that often have their roots in early-life trauma. Doctors who coordinate treatment with mental health providers must also navigate at times thorny privacy issues, and brace for the possibility that patients will sell buprenorphine prescriptions on the black market.To face such complexities after a mere eight hours of training, Waller said, “it can be pretty scary for someone in primary care.”

For these reasons and others, physicians groups have supported the training programs around medication-assisted treatment for opioid use disorders, but only to a point.The largest physician group, the American Medical Association, backs increased training for the medication-assisted treatment of opioid use disorders among its members, but it opposes mandatory training.

The AMA believes that such training may not be relevant to all primary care physicians. Some doctors do not prescribe opioids, for instance, while medical practices might lose money on such treatments because of inconsistent insurance coverage of opioid addiction medications.

Dr. John Meigs, president of the American Academy of Family Physicians, said opioid abuse “is so rampant, and we’re the specialty with the broad training in comprehensive, whole-person care, that it is appropriate for us to help take care of this need.”

But Meigs himself, who has practiced medicine in rural Alabama for 34 years, said he “has not had time” to become certified, and that he does not know how long the process takes. It is, however, something he intends to do in the future, he said.