By Mark Gold, MD
As America continues to deal with an opioid overdose epidemic of staggering proportions, public health initiatives are faced with the needs of the more than 1.7 million people who are suffering from opioid use disorder (OUD) as of 2017.1 This crisis is exacerbated by the shortage of health care practitioners trained and able to use FDA approved medication, like buprenorphine, to treat patients with an OUD. In a nation with a population exceeding 320 million, there are only 1100 psychiatrists specializing in addiction—the need for providers who are equipped and able to treat OUD is greater than ever. In a recent paper from the Yale School of Medicine Srinivas B. Muvvala, MD, MPH, Ellen Lockard Edens, MD, MPE, and Ismene L. Petrakis, MD, call upon psychiatrists and mental health professionals to play a more active role in addressing the current opioid crisis.
Why are Psychiatrists so Important?
Psychiatrists are unique among physicians due to their specialty training. They are well schooled in how to deal with trauma, depression, anxiety, suicidal behavioral tendencies, and other frequent comorbid psychiatric conditions, and can deal with co-occurring disorders effectively. While psychiatrists focus on the brain and behavior, they are also medical physicians and comfortable treating complex and co-morbid diseases. The high frequency of comorbid psychiatric illnesses with OUD means that patients with OUD often end up in psychiatric offices even when their substance use isn’t the explicit reason they are coming to the practice. For example, a patient may visit a psychiatrist for an evaluation suffering from depression only to find out that they have an important co-morbid, alcohol use disorder. For this reason, psychiatrists should be screening for OUD too, and be able to enact office-based interventions grounded in medication-assisted treatment (MAT).
Unfortunately, while the data and evidence supporting the use of MAT for OUDs is overwhelming, physician prescription rates and use of MATs have been slow to gain traction. Some psychiatrists are simply too busy— their practices are full and they cannot accept new patients. For others, the lack of enthusiasm about MATs is due to inadequate prescriber education about how MAT for OUD works to stabilize brain chemistry, how it can be incorporated into practice, and its efficacy. General psychiatrists do not routinely incorporate addiction treatment in their practice, and a national survey indicated that more than 80% were uncomfortable providing office-based MAT for OUD. The authors point out that it is crucial to change this, as the level of integrated mental health care and relapse prevention counseling that can be provided by psychiatrists quite efficiently and timely in an office-based setting makes psychiatric offices an optimal place to provide care for OUD.
“Psychiatrists are in an excellent position to meet the requirement that buprenorphine be given in conjunction with psychosocial services,” Muvvala, Edens, and Petrakis write. “Psychiatrists can provide in-house counseling and also work collaboratively with other disciplines (e.g., psychologists, social workers, nurses, and counselors).”
Reshaping the Psychiatric Response to the Opioid Epidemic
Considerable evidential data supports the efficacy and ease of treating OUD with buprenorphine in office-based settings, and since the Drug Addiction Treatment Act of 2000 helped expand the clinical context of buprenorphine by reducing the regulatory restrictions for prescribing, psychiatrists can begin to prescribe buprenorphine after completing an 8-hour training. Between this training and established mentoring programs, the authors recommend providers begin incorporating buprenorphine treatment into already established and routine psychiatric practice.
Additionally, buprenorphine education should be prioritized in all residency programs for physicians in training. Currently, only 40% of 85 surveyed residency programs offer buprenorphine waiver training, despite the low-investment requirement of a single month of addiction treatment experience. Research has indicated that psychiatrists who acquire training to prescribe OUD medication as residents are more likely to prescribe it than those who receive training later on in their practice. Training during residency is key to increasing prescriber literacy and comfort with existing OUD medications, destigmatizing the disorder and its treatment, and stressing upon professionals the importance of integrating care.
Looking from the Past into the Future
It is worth revisiting the ground-breaking report “Addiction Medicine: Closing the Gap Between Science and Practice,” by Columbia University. Published in June of 2012, this 5-year study found that, despite the prevalence of addiction, the enormity of its consequences, the availability of effective solutions and the evidence that addiction is a disease, both screening and early intervention for risky substance use are rare. Only about 1 in 10 people with addiction involving alcohol or drugs other than nicotine receive any form of treatment. The Yale group have taken these findings and built a modern approach calling psychiatric physicians to action. The report concludes: “Of those who do receive treatment, few receive anything that approximates evidence-based care. This compares with 70% to 80% of people with such diseases as high blood pressure and diabetes who do receive treatment. This report exposes the fact that most medical professionals who should be providing addiction treatment are not sufficiently trained to diagnose or treat the disease, and most of those providing addiction care are not medical professionals and are not equipped with the knowledge, skills or credentials necessary to provide the full range of effective treatments.”2 We have made some progress, but it has been slower than we would have liked and predicted at the time this study was published.
The next logical step toward better addressing OUD and curbing the current public health crisis is looking for ways to overcome systemic barriers to ensure that treatment is easier to access. New medications have been approved by the FDA offering psychiatrists more options in detoxification, agonist maintenance, and long-acting formulations of safe and effective MATs. Psychiatrists need to keep up with these advances and provide state-of-the-art evidence-based treatments in the offices, clinics, and hospitals where they practice.
“Addressing the national opioid epidemic is the responsibility of every psychiatrist,” Muvvala, Edens, and Petrakis conclude. “With commitment and a modest investment in further training, the expertise of psychiatrists in treating other psychiatric disorders can be extended to the effective treatment of OUD. We can and should be part of the solution to the current opioid epidemic.”
Center for Behavioral Health Statistics and Quality (CBHSQ). (2017) National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2018. Retrieved from https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis#five.
Addiction Medicine: Closing the Gap between Science and Practice. (2017, April 14). CASAColumbia. Retrieved from https://www.centeronaddiction.org/addiction-research/reports/addiction-medicine-closing-gap-between-science-and-practice.
Muvvala, S.B., Edens, E.L., & Petrakis, I.L. (2019, Feb 1). What Role Should Psychiatrists Have in Responding to the Opioid Epidemic? JAMA Psychiatry, 76(2), 107-108. doi:10.1001/jamapsychiatry.2018.3123