With over 450 patients on Medication for Opioid Use Disorder (MOUD) engaged in our primary care-based programs we have learned a thing or two about how to do this work in primary care.
We are fiercely passionate about this work and have been leading voices in the design of programs that promote health and wellbeing and reduce stigma, shame, and more importantly risk of death.
In Oregon, we started out as two primary care providers (PCP) with a passion for addictions work, which has turned into 16 DATA-waivered PCPs and a multidisciplinary team who care for 450 patients receiving buprenorphine across two clinics, a rural health center and a Federally Qualified Health Center. These programs were funded with the help of HRSA and state funding for expansion of primary care-based substance abuse treatment for OUD.
In Massachusetts, we began ten years ago with three of our family physicians prescribing buprenorphine. We now have a team of 8 attending physicians prescribing MOUD. For the past 6 years all of our family medicine residents graduate with two years of experience caring for patients prescribed buprenorphine. These programs have been expanded and supported by a nursing team that includes an RN, LPN, and medical assistant dedicated to the care of more than 250 patients with OUD in central Massachusetts.
Our programs are known for their harm reduction and relationship-based approach. We tolerate periods of instability. We meet patients where they are at. We avoid practices that evoke shame and instead foster transparency and accountability.
Unfortunately, there are some pretty strong myths that exist about how to care for patients struggling with opioids. We want to call out and debunk false beliefs that create unneeded barriers to life saving treatment.
Myth #1: Mental Health Treatment is Required
Not all patients need counseling to recover from OUD. Unfortunately, counseling is often mandatory for patients receiving buprenorphine. Buprenorphine should never be withheld from someone who declines counseling. Whether a patient is addressing underlying mental health conditions at the outset of treatment is less important. What is more important is if they are decreasing their opioid use and taking buprenorphine. The medication is a life-saving, harm-reducing intervention; counseling is secondary and should be treated as such.
Certainly some patients greatly benefit from counseling; there are some patients for whom counseling will be an important part of their treatment plan once they are in the maintenance phase of treatment. We have patients who request counseling several months after induction when their lives are starting to stabilize, and they gain insight into underlying factors, or wish to plan for their futures. For some patients this is their preferred time for engagement in counseling.
Myth #2: Patients Must Have a Behavioral Health Assessment
Patients should be initiated an MAT as quickly as possible. Yes, they need assessment of some kind (medical, nursing, psychosocial); but clinics should not build systems that require elaborate behavioral health intakes or screenings. These systems act as barriers to treatment and put patient’s lives at risk. Although the need for medication should not be seen as a crisis, there should be a sense of urgency to initiate treatment. Each day that a patient cannot access buprenorphine is a day they are at risk of death. Many patients entering treatment already know how to use buprenorphine safely and know their withdrawal symptoms well. It is helpful to have your behavioral health provider meet the patient and assess their appropriateness for primary care-based treatment; however, this brief assessment should not delay initiation.
Myth #3: Induction Must Be in the Clinic
More and more of our medication inductions are being done at the patients’ home. Why? Because it is often more patient centered. Home inductions can be accomplished as safely as office-based inductions. Practices should move to home-based induction when possible. Why? Because to be ready for induction, most patients must be in a level of withdrawal that is pretty uncomfortable. They may live far away. The clinic may not have a space where patients can sit during the induction. It is often less burdensome on the clinic as it doesn’t use as much staff or space and is more comfortable and convenient for the patient. Home induction removes a barrier to treatment and reduces the burden on the primary care practice.
Myth #4: Buprenorphine is Treated like Full Agonists
Stigma and misunderstanding can color patient, family member, and provider views on buprenorphine. Patients and families benefit from education about buprenorphine and how it is similar and different to other medications and substances. Harm reduction principles should be offered and explained. An example of this:
Yes, buprenorphine is “trading” one drug for another. It is trading a drug that will kill you, heroin/fentanyl, for a drug that won’t kill you, buprenorphine.
Patients and families become allies in treatment when they understand the relative safety of buprenorphine.
Myth #5: Trauma Must Be Screened For and Treated
Approximately 75% of people being treated for substance use disorders (SUDs) report a history of adverse childhood experiences (ACE). Rates of trauma are very high in this population. Many adults living with OUD have been victims of sexual and physical violence. Screening for trauma in this population is not needed because the prevalence is known to be very high. Instead we propose the use of a universal precaution approach to trauma informed care (TIC). With universal precautions, TIC is provided regardless of knowledge if whether someone has a trauma history.
Additionally, OUD is a life-threatening condition and some patients can recover from OUD without addressing trauma. Addressing past trauma and current toxic stress should not be a requirement for treatment.
Myth #6: Patients Must Attend Groups
To a certain extent treatment needs to be individualized. For some patients a group medical visit or support group will be a helpful format for them to engage in treatment. For some patients group treatment is not something that they feel comfortable doing for a variety of reasonable reasons. We don’t mandate groups and don’t think this should be a requirement of treatment.
Whether in group or individual treatment, we attempt to meet patients where they are at, using Motivational Interviewing skills like empathy and evoking and reinforcing change talk. Rolling with resistance and using trauma-informed techniques of transparency and anticipatory guidance can help build trust and relationship.
Myth #7: The Providers Are the Only Team Members Who Need Training
Something that we have learned over time is that providing MAT in your clinic requires a culture shift. We have found that it takes training our entire staff on the intersections of trauma, substance use disorders, and mental health. We have found that we need to provide education on SUDs; dispelling myths about addiction and promoting harm reduction principles. Behavioral health providers can help train staff about MAT and help to reduce the stigma that is still prevalent in our communities and nationally.
For more reading that inspired this post see these two articles:
Wakeman, S. E., & Barnett, M. L. (2018). Primary Care and the Opioid-Overdose Crisis – Buprenorphine Myths and Realities. The New England Journal of Medicine, 379(1), 1–4. http://doi.org/10.1056/NEJMp1802741
Martin, S. A., Chiodo, L. M., Bosse, J. D., & Wilson, A. (2018). The Next Stage of Buprenorphine Care for Opioid Use Disorder. Annals of Internal Medicine, 169(9), 628–635. http://doi.org/10.7326/M18-1652