A primary care physician assistant’s work typically looks a lot like that of other providers in the field: conducting physical exams, administering tests and checkups, and taking other steps to ensure that a patient is generally in good health. But in the middle of America’s deadly opioid epidemic, Lindsay Fox has taken on another task too — figuring out how to treat patients in the throes of drug addiction.
“This is not an easy group of people to treat,” Fox, who sees patients at the Southwest Mesa Clinic in Albuquerque, told me. “However, to bear witness and share space with someone who … has been supported by their family and their clinic and their provider, and has really challenged themselves to transition off of opioids and find sobriety, that’s one of the most rewarding things I’ve ever witnessed as a provider. Looking back at all the stories, that’s really what keeps me going.”
In the US, though, most primary care providers don’t get past the initial hurdle that Fox mentioned — the potential difficulty presented by people with addictions. So many don’t even have the legal ability, as Fox does, to prescribe buprenorphine, one of the medications widely regarded as the gold standard for opioid addiction care.
Even as drug overdose deaths rose to a record 64,000 in 2016, at least two-thirds of which were linked to opioids, the statistics show that US doctors aren’t on board with fully dealing with this crisis: According to the White House opioid commission’s 2017 report, 47 percent of US counties — and 72 percent of the most rural counties — have no physicians who can prescribe buprenorphine. And only about 5 percent of the nation’s doctors are licensed to prescribe buprenorphine in the first place.If you talk to America’s leading drug policy experts, one of the most common solutions they point to in confronting the opioid crisis is fixing these numbers — to massively expand access to addiction treatment. Yet access remains a problem: Only 10 percent of people with a substance use disorder get specialty treatment, in large part due to a lack of affordable and available treatment options, according to a 2016 report from the surgeon general.
Doctors’ reluctance to provide opioid addiction care shouldn’t be due to the science. Buprenorphine and other medications like it, such as methadone, are well-studied and proven to be effective. Studies show the medications cut the mortality rate among opioid addiction patients by half or more and keep people in treatment better than nonmedication approaches.
In France, the government loosened the rules around doctors prescribing buprenorphine in response to an opioid epidemic in the 1990s — and overdose deaths declined by 79 percent from 1995 to 1999 as the number of people in treatment went up, according to a 2004 study published in the American Journal on Addictions.
I went to New Mexico to figure out what’s behind clinicians’ reluctance to offer addiction treatment. There, I met with medical providers taking part in a conference for an elaborate training and support program known as Project ECHO (Extension for Community Health Outcomes), which supports providers involved in, among other things, addiction treatment. I asked them about the hurdles that they faced before deciding to treat addiction in their practices.
Some providers complained about the legal obstacles to prescribing buprenorphine. In the US, federal laws impose special rules to prescribing buprenorphine — requiring eight hours of training for physicians and 24 hours of training for physician assistants and nurse practitioners to obtain waivers to prescribe the medication.
But many providers said that the initial barriers they faced were more complicated than just going through the training courses. There are real structural barriers, they said, particularly the fear that patients with addiction are more complicated than the typical patient, and that these providers, even if they want to treat those patients, won’t have the time and resources to do it.
It’s true that patients with addiction can be more complicated. Long neglected, or even rejected, by the health care system and society at large, people with addictions often have other medical conditions, including mental health issues, along with a variety of socioeconomic problems such as joblessness, homelessness, and family turmoil.
Most doctors have historically gotten zero to very little training on addiction in medical school, according to Anna Lembke, a Stanford psychiatrist and author of Drug Dealer, MD. And now treating these patients may involve expertise and issues beyond addiction care? It’s a big ask.
Dealing with all of these issues can create “time barriers,” Fox said. Treating addiction “requires a lot of patient education. It requires a lot of time spent with the patient getting a history — getting the history of the addiction, getting the history of the present illnesses. Basically, everything you do in an appointment but to a detail that you can identify the patient’s opioid use.”
The barriers exist, in part, because of expectations built into the health care system that push medical providers to see a lot of patients quickly, maximizing how many people and services can be billed. “That’s been a barrier — to try to convince employers that I needed extra time,” Fox said.
There are also trust issues. “It takes a while to build rapport with this population because substance abuse is a very personal topic,” Fox said. “We can’t treat it like toenail fungus or something that is very basic. It takes time for people to trust you, and to be able to reveal something that brings a lot of shame to people.”
And even once patients are on buprenorphine and stable, Fox said, that’ll only begin the process of solving other problems: “Now that you’re stable and not worried about having withdrawal effects and not worried about losing your job or losing your children, what do you want to do next?”
Altogether, treating a patient for addiction isn’t just treating the addiction — but the many other issues, from homelessness to mental health, that can affect a person’s wellness too. For health care providers, addressing all of this can be time-consuming and difficult, even outside of their personal expertise.
So how do you fix this? How do you get more health care providers like Lindsay Fox?
The answer, in short: If we expect doctors, physician assistants, nurse practitioners, and others in health care to help solve the opioid epidemic, they must be equipped with the resources, training, and backup to do so. Only then will enough providers feel comfortable taking on an overdose crisis that’s become the deadliest in US history.
Doctors are worried they can’t handle addiction patients
As I’ve asked health care providers around the country what it would take to get more of them on board with confronting the opioid crisis, I’ve heard the same story again and again. Lembke, the Stanford psychiatrist, summarized the general sentiment:
“I think too much is being asked of primary care doctors, who are already overwhelmed with high patient loads and minimal support to take care of multiple complex chronic illnesses. They have good reason to be concerned about adding one more chronic illness – addiction – to their to-do list. On the other hand, we do not have enough addiction medicine doctors to meet the need, so combating the opioid epidemic will require all hands on deck.”
That helps explain why the great majority of opioid overdose survivors, based on a recent study of Massachusetts survivors published in the Annals of Internal Medicine, aren’t prescribed medications for opioid addiction in the year following a nonfatal overdose.
It’s not simply because health care providers think medications like buprenorphine are ineffective. In a 2017 study published in the Annals of Family Medicine, rural doctors who had the credentials to prescribe buprenorphine but didn’t prescribe it said their biggest concerns were time constraints, lack of specialty backup for complex problems, lack of available mental health or psychosocial support services, fear of diversion, and the attraction of drug users to their practice. A 2014 study in Annals of Family Medicine of doctors, both urban and rural, in Washington state produced similar results.
“Our findings suggest that more than a training course is needed to convert trainees and primary care clinics into service providers in areas that have no access to buprenorphine,” the 2014 study concluded.
Fox shared a story to put clinicians’ concerns in context. She was dealing with a very technical issue involving a patient’s buprenorphine — an issue so technical, she said, that she wouldn’t know how to handle it without outside help.
She had a patient in treatment for opioid addiction who needed a colectomy, a procedure to remove part of the colon (to treat, for example, cancer). It would require getting the patient on opioid painkillers temporarily for the surgery.
But buprenorphine, the patient’s anti-addiction medication and an opioid itself, can block the effects of other opioids. So Fox had to figure out how to temporarily wean the patient off buprenorphine — without triggering withdrawal, which can lead to a relapse — so the surgical team could properly administer opioid painkillers. And then, after all that, she would have to figure out how to get the patient off the new painkillers and back on buprenorphine.
“That’s pretty technical,” Fox said, “but it’s doable.”
Fox knew whom to call. She reached out to her colleagues at Project ECHO, an international program that uses teleconferencing technology to connect health care providers and specialists to make it easier to share previous lessons and expertise on all kinds of medical issues. They managed to guide Fox through the process, and the patient eventually ended back on buprenorphine with no major problems.
But what would happen if Fox didn’t have access to ECHO or any other kind of structural support for dealing with this kind of patient? What if she was out in rural West Virginia — without the resources to know how to deal with such a technical case, and without access to an ECHO program or anything like it?
“I don’t really know what I would do,” she said.
It’s that point of not knowing what to do where providers often end up or fear ending up — and so they decide that perhaps these patients aren’t really worth the hassle, or that they’re not capable of adequately serving these patients at all. And while Project ECHO is far from the only support program that can help these providers, it helps demonstrate some of the issues that need to be overcome to truly get the health care system on board with fighting the opioid crisis.
With backup, doctors can provide more addiction treatment
Project ECHO attempts to address some of the structural gaps in the health care system. Using teleconferencing tools, it aims to build capacity in underserved areas, from rural counties to minority communities. ECHO currently has at least 17,200 participating health care offices around the world.
Starting in New Mexico in 2003, ECHO first tried to link specialists and primary care providers to improve treatment for hepatitis C — through teleconferencing technology, primary care providers across the state could share information with one another about treatment and continue to stay connected on a regular basis
Studies of ECHO have shown promise, finding that, for hepatitis C, patients of ECHO providers saw similar health care outcomes as specialists’ patients. Over time, ECHO has expanded to address more medical conditions, including addiction.
ECHO should help address at least one of the big complaints from primary care providers about treating addiction: poor access to specialists who are more likely to know their way around complex problems. And a 2016 study published in Substance Abuse concluded that ECHO helped facilitate an expansion of clinicians providing buprenorphine to patients (but patient outcomes weren’t measured).
Here’s how it works: The program links specialists at a hub — say, a university, hospital, or other academic or medical setting — with primary care clinicians around a region, state, or country. During each meeting, a primary care provider (or more) shares a complex patient case. As everyone on the call provides feedback, people are not only helping solve the case but also effectively conveying lessons that they’ve gained from treating complicated patients throughout their own practices.
Additionally, a teleconferencing session can include a sort of webinar on an area of research, like new treatments or newly discovered medical conditions, to help providers continue their education on treatment after training.
In Albuquerque, I got to see several of these ECHO sessions in action. Before, it was hard for me to imagine how just one case study every week or two could impart much of an education for providers. But what stuck out to me is just how many lessons can stem from one case.
One of the patients discussed in a session was a law enforcement official, whose drug use — which included opioids, benzodiazepines, tobacco, and marijuana — had spiraled out of control as he and his clinicians attempted to deal with his chronic pain and depression. His marriage and job were strained as a result of the drug use, and the collapse of either would only worsen his situation, which was already mired by a lack of financial resources to obtain proper behavioral health care.
To make matters worse, the patient didn’t want to come to terms with his addiction. He saw himself as a masculine, self-reliant John Wayne kind of guy. The idea that his drug use might have gotten out of control — and turned into an addiction — was not something that he was willing to accept. The clinicians on the call viewed this as a self-stigmatization, but instead of dismissing it offhand, they talked about how to work around it.
Ultimately, the clinicians landed on emphasizing the risk of overdose rather than addiction. “You’re bending the truth, but you’re bending the truth for a good purpose,” Brant Hager, a psychiatrist based in Albuquerque, said during the call. That, they said, could help ease the patient into taking buprenorphine and tapering off other drugs.
In reaching this conclusion, a lot of topics were covered: not just opioid addiction but the stigma that can come with it, the opioid overdose antidote naloxone, the social and mental health contributors to addiction, the commonality and problems of someone using multiple drugs (which can interact in ways that make the drugs more dangerous), pain management, and even the possibility of medical marijuana. I learned a lot in under an hour.
The weekly or biweekly teleconferences, though, are only one part of ECHO. The program also provides more traditional training seminars, including the training sessions that providers need to get certified to prescribe buprenorphine. Fox, the physician assistant from Albuquerque, said ECHO helped her get her buprenorphine waiver “sooner rather than later.”
And crucially, ECHO also acts as a networking tool — giving clinicians and specialists a means to meet and, ultimately, collaborate. “That’s where Project ECHO has been very helpful,” Fox said. “It’s connected me with a community of people that are teachers and who have experience and that I can call or email and say, ‘Hey, I just want to run something by you.’”
In providing training and specialist backup, ECHO is trying to fill a medical education gap in the US for addiction treatment. ECHO’s leaders admit that they can’t possibly fill the whole gap, but they hope to at least help. “In no way does ECHO replace basic undergraduate or graduate medical education,” Miriam Komaromy, who oversees ECHO’s addictions program, told me. “ECHO really follows that.”
Project ECHO is not without its critics. After Congress passed a law in 2016 encouraging federal support for ECHO programs, Chris Langston, the vice president of health care services at the Aging in New York Fund, cautioned that there isn’t robust empirical evidence for ECHO and patient outcomes outside of hepatitis C care. In his view, we should demand much more research before expanding the model to help with other medical conditions.
Still, Langston said there is reason to believe ECHO could work for addiction as it worked for hepatitis C. A problem with hepatitis C treatment, Langston said, seemed to be that primary care providers simply didn’t believe it was in their wheelhouse to treat it — even if they knew what to do, they thought it should be left to specialists. ECHO may have changed this, Langston said, by legitimizing the treatment of hepatitis C in primary care — essentially, boosting providers’ self-efficacy.
“Nobody was treating hepatitis C at all outside the academic center at the University of New Mexico,” he said. “It wasn’t like people were doing it badly. I think the best interpretation was that the physicians didn’t think they were supposed to do this.”
That self-doubt has historically applied to many primary care providers when it comes to addiction, Langston said. It’s not because these providers aren’t aware of effective opioid addiction treatments like methadone and buprenorphine; they tend to believe those issues should be left to other providers. So, he said, perhaps Project ECHO could help boost self-efficacy among primary care providers and encourage them to treat addiction on their own.
But, again, Langston cautioned that more research into ECHO is necessary.
Mia Lozada, a doctor who treats opioid use disorder at the Indian Medical Center in Gallup, New Mexico, said that a boost in self-efficacy is part of what ECHO did for her. “When an individual doesn’t feel as isolated — doesn’t feel as if you’re an island trying to treat opioid use disorder — that confidence will beget more confidence in a given clinic, a given hospital, or a given region,” Lozada said. And that confidence, she added, will make doctors more likely to treat addiction.
To address the opioid crisis, doctors need a lot more institutional support
As Komaromy acknowledged, ECHO can’t address all the problems providers face. It is, after all, just one program trying to address a slice of a systemic problem.
“Addiction has typically fallen between the cracks of behavioral health and physical health, and no one has really wanted to own it as a problem,” Komaromy said.
Some of that is caused by stigma and misconceptions about addiction. After decades of the US treating addiction as a criminal justice problem instead of a public health concern, much of the public, including health care providers, still views addiction as an issue that demands a punitive response, and sees those with addiction as part of the problem instead of people who need help.
For example, a prominent belief about patients with addictions is that they’re more likely to lie to clinicians. The reality is that all kinds of patients lie to their providers to some extent — to avoid shame and embarrassment. But to the extent that this is true for addiction patients in particular, it may be a survival mechanism in the face of a society that often stigmatizes people who use drugs.
“If you think about how hard it is to be addicted and struggling, those behaviors are coping strategies that have been developed by people who have been using illicit substances in order to survive,” Komaromy said. “They’re afraid of being rejected in the medical setting, and they often have had very bad experiences working with doctors and other health care providers. So their first instinct is to sort of say what they think the provider wants to hear. Then when the provider realizes that’s not true, the whole relationship breaks down.”
There’s also the idea that addiction patients are particularly hard to treat. While people with addiction do often present other complex problems, that may be a part of a vicious cycle — a result of the health care system failing to treat people with addiction in the first place.
“If you only saw breast cancer after it metastasized, you would think breast cancer is very, very hard to treat,” Leslie Hayes, a family physician in Española, New Mexico, who was named a “Champion of Change” by the White House in 2016, told me. “That’s what we’re doing with substance use disorder. We’re not diagnosing alcoholism until patients come in with end-stage cirrhosis. We’re not diagnosing opioid use disorder until they’ve overdosed several times. We’re not diagnosing it soon enough.”
To the extent that patients with addiction are more complicated, programs like ECHO can help. But it can’t address the full scope of the problem; as the 2017 study of rural doctors found, concerns beyond having access to specialty backup include time constraints and a lack of available mental health or psychosocial support services.
Addressing these kinds of issues will simply require more people involved in addiction work — staff to help a clinician handle more patients, and staff or referrals that can offer mental health and psychosocial services. “Physicians just need more support,” Holly Andrilla, a co-author of the study on rural doctors, told me.
Vermont — with its innovative “hub and spoke” system, which works to integrate addiction treatment into the rest of health care — has attempted to address concerns about poor support for providers. To make addiction treatment more accessible, the state offers providers teams, made up of a nurse and a behavioralist, that handle the extra workload that comes with addiction patients, while the clinician can continue to focus on treating the condition itself.
When I checked out Vermont’s hub and spoke system in 2017, providers consistently emphasized how crucial those teams were to the program. Heather Stein, a primary care doctor at the Community Health Center in Burlington, said the teams alone made a huge difference in her practice. Before, she felt she couldn’t take more patients, “because I felt like there were so many i’s I had to dot and t’s I had to cross in every office visit.” But now her team calls the patients, makes sure they’re seeing a therapist, and gets them to come in for pill counts. “All I’m really having to address is their medical symptoms and their medical issues,” she said. “It made me able to take on a larger panel of patients.”
There are also broader structural issues with health care costs. For example, health insurers often impose barriers to avoid fully paying for addiction treatment. This makes addiction treatment more expensive for patients, but it also discourages health care providers from offering addiction treatment. For providers, it’s a simple calculation: Why treat people who will have complicated medical conditions if you can accept far fewer patients who will take less time yet reliably pay at the same or higher rates?
There are ways around this problem as well. Virginia, for instance, in 2017 boosted reimbursement rates for addiction providers through its Medicaid program. While the results are early, independent evaluations from researchers at Virginia Commonwealth University have already found some promising results: The number of clinicians who provided addiction care went up, the number of Medicaid members receiving treatment also rose, and the number of emergency department visits related to opioid use disorder declined. Looking at these results, other insurers, public and private, could boost their own reimbursement rates for addiction care.
Beyond encouraging existing providers, more could be done to bring in new clinicians to addiction care. Lembke of Stanford told me of her potential solution to the problem — what she called AmeriCorps for addiction treatment: “Why don’t we recruit these young people and say, ‘Hey, we’ll pay back your med school loans, in part, if you spend a couple years in rural West Virginia treating people with addiction’? We need to come up with creative ways like that to bring people into the workforce.”
There are also legal barriers. Besides the training requirements that health care providers need to meet to prescribe buprenorphine, the federal government also sets caps on how many patients each provider can prescribe the drug to. The cap can be raised, but only by meeting additional hurdles. These are barriers that aren’t in place for a lot of other drugs — not even opioid painkillers, the initial cause of many patients’ addiction.
Providers told me that some rules are needed (since buprenorphine is an opioid that can be diverted for misuse). But they argued that the current rules are tilted too far in a burdensome direction. Congress could loosen the restrictions — just as France relaxed its rules for buprenorphine prescribers in the 1990s, and subsequently saw big drops in drug overdose deaths.
So while there are structural issues, they’re not insurmountable — whether it’s through a program like ECHO, a systemic approach like Vermont’s hub and spoke system or Virginia’s Medicaid reforms, legal changes, or, more likely, all of the above and more. There just needs to be a demand for such reforms, from providers and the public, to treat addiction as a health care problem — and not just for opioids, since the next addiction crisis may very well involve a whole different class of drugs.
In the end, this could help health care providers treat the patients they’re already seeing. After all, more than 20 million people in America have a substance use disorder of any kind, from alcohol to opioids. Chances are providers who don’t treat addiction are already seeing some of these patients, even if they’re not formally diagnosed yet.
As Hayes put it, before she got her buprenorphine training, “I was already taking care of all of these patients anyway. I just wasn’t able to treat their opioid use disorder.”