Q&A: How can PCPs properly manage patients with opioid use disorder?

A new medical education curriculum in an area hit hard by the opioid epidemic will help fill a gap in addiction management training, according to a press release.

The CDC estimates there were more than 101,000 predicted overdose deaths in the U.S. — many of them tied to opioid use — in the 12-month period ending in June 2021.

“We need better addiction medicine education at all levels,” Tiffany Lu, MD, MS, an assistant professor of medicine in the division of general internal medicine at Montefiore Medical Center and Albert Einstein College of Medicine in New York City and director of the Montefiore Buprenorphine Treatment Network, said in the press release.

The medical education curriculum is being funded by a 3-year, $447,000 grant from the Substance Abuse and Mental Health Services Administration. It will expand addiction medicine education and training programs for medical students at Albert Einstein College of Medicine and residents at Montefiore Health System. Healio spoke with Lu to learn more about the curriculum, what physicians can do to help curb the opioid epidemic and more.

Healio: What does the curriculum entail?

Lu: This longitudinal addiction medicine curriculum entails expanding education in both Albert Einstein College of Medicine Medical School and for Montefiore Health System’s residency training programs.

For medical students, we will introduce preclinical and clinical education on addressing stigma around addiction, providing medications for addiction treatment, offering overdose prevention counseling and facilitating safe opioid management.

For internal medicine medical residents, a 2-week clinical rotation that includes inpatient and outpatient training in addiction medicine is now required. This clinical rotation is also available as an elective to family medicine and other medical residents.

For both medical students and medical residents (internal medicine, family medicine and psychiatry), an 8-hour buprenorphine training that integrates clinical faculty expertise on delivering care to patients in our Bronx communities will be offered and required.

Healio: Most new physicians were never formally taught how to manage addiction. How should they properly manage addiction?

Lu: First and foremost, physicians need to approach addiction as a chronic illness that deserves care across the continuum of health care settings with a nonjudgmental patient-centered approach, as much as the way they would approach other chronic illnesses like diabetes and hypertension.

Second, physicians also need to learn about the clinical tools to appropriately evaluate and diagnose substance use disorders, and help patients navigate community-based resources for substance use disorder treatment. Physicians should also know about effective medication and psychosocial treatment options for substance use disorders, including methadone, buprenorphine and naltrexone.

Third, drug use is a part of our society, so it is important for physicians to understand that people who are using drugs have varying goals and readiness for stopping drug use. Being able to talk with our patients about practical strategies to reduce harms related to drug use, which includes naloxone for overdose prevention, safer injection practices and prevention of HIV and viral hepatitis, will help physicians meet patients where they are at.

Healio: What should primary care physicians know about pharmacological opioid use disorder treatments? When should they be prescribed?

Lu: All PCPs should take advantage of our ability to prescribe effective medication treatment for opioid use disorder, or OUD, in particular buprenorphine. Buprenorphine is a well-studied partial opioid agonist medication that can be prescribed in diverse medical settings, including in primary care, and can help persons with OUD reduce their risk of overdose death, improve engagement in OUD treatment, reduce or stop opioid use, and improve psychosocial functioning. It can be prescribed by any PCP who applies for a [Drug Enforcement Agency] waiver — the 8-hour training is no longer required for obtaining a basic prescribing waiver. Patients can be successfully started and continued on buprenorphine treatment through their primary care provider team, with dramatic life-changing outcomes.

Healio: How can physicians reduce the stigma of opioid use disorder treatment?

Lu: We can start by offering it. For too long, physicians have had the attitude of avoiding talking to patients about substance use and simply referring patients out to specialty programs. However, these programs may not be accessible, affordable, feasible or desirable. When we have physicians silo addiction care to specialty settings, we are sending a message to patients that their addiction needs are not part of their medical and psychosocial care needs. Learning how to integrate assessments and counseling about addiction treatment in our practices is an important way to reduce the stigma.

In learning how to assess and counsel patients on addiction treatment options, physicians also need to practice person-centered language and lessen the stigma that's been long associated with the use of outdated terms such as “abuse,” “abuser” and “addict.”

Healio: What harm reduction and overdose prevention strategies do you recommend for use in a primary care setting?

Lu: First and foremost, primary care teams need to be aware that we are in the midst of an overdose crisis that is largely driven by widespread contamination of the street drug supply with synthetic opioids such as fentanyl. Effective overdose prevention strategies include prescribing naloxone to any patient (or to a family member or friend of a person who uses drugs), especially if using heroin or other opioids. Also, discussing ways to reduce overdose risk — such as going slowly and testing doses before use, not using alone, and not mixing with alcohol or other substances that can over-sedate — can and should be done in primary care settings.

Also, PCPs can help people who inject drugs access evidence-based harm reduction services by referring patients to community-based syringe service programs, and facilitating screening and treatment of viral hepatitis, HIV and sexually transmitted infections. To that point, people who use drugs can be successfully treated for their viral hepatitis and HIV, which reduces harms on both an individual level and a public health level. PCPs are poised to treat hepatitis C and HIV through a chronic care approach.

Healio: When should a PCP refer patients with opioid use disorder to an addiction specialist?

Lu: Referring to an addiction specialist depends on patient complexity and comfort of the PCP. When patients are not achieving treatment goals in primary care, which may be because of co-occurring substance use disorders or psychiatric diagnoses, then they may benefit from evaluation by local addiction specialists or specialty addiction programs.

PCPs can also benefit from joining mentorship networks with addiction specialists, which can be done through local provider support systems, or through national platforms like [Providers Clinical Support System] or Project ECHO.

Healio: How do you intend to share your curriculum with other health systems?

Lu: We will be compiling educational tools, resources and evaluation outcomes throughout our project implementation. We will be sharing this locally with medical schools and hospital systems across the greater New York region, and we will use local, national and regional conferences and peer-reviewed journals to share the curriculum.

References

Albert Einstein College of Medicine and Montefiore Health System receive federal grant to expand addiction medicine education and training. https://www.montefiore.org/body.cfm?id=1738&action=detail&ref=2088. Published Dec. 16, 2021. Accessed Jan. 5, 2022.

Jamison RN, et al. Opioid Manag. 2014; doi:10.5055/jom.2014.0234.

Jamison RN, et al. Pain Med. 2016. doi: 10.1111/pme.12871.

Statement from Dr. Rahul Gupta on Today’s CDC overdose death data. https://www.whitehouse.gov/ondcp/briefing-room/2022/01/12/statement-from-dr-rahul-gupta-on-todays-cdc-overdose-death-data-2/. Published Jan. 12, 2022. Accessed Jan. 19, 2022.