Opioid crisis: Few MDs on front line
In 2013, when the number of New Hampshire deaths attributed to opiates was just beginning to attract attention, Dr. Molly Rossignol became one of a handful of doctors in the state certified by federal health agencies to prescribe the drug buprenorphine to combat addiction.
Any doctor so certified by the DEA ends up on a website hosted by the Substance Abuse and Mental Health Services Administration, unless they opt out.
Rossignol, working in Manchester at the time, failed to uncheck the right box on her application. On the day she got her federal waiver to prescribe buprenorphine, her office had 45 phone calls.
That was three years ago. Since then, the number of New Hampshire residents addicted to opioids has increased dramatically, but the number of doctors qualified to offer what professionals call “medication-assisted treatment” has not.
The reluctance of doctors to take the plunge into addiction medicine is one of the major barriers to treatments that could make a big difference, according to those on the front lines of the opioid crisis.
There are at least 4,000 licensed medical doctors practicing in New Hampshire, according to the New Hampshire Medical Society. The Center for Substance Abuse Treatment website lists only 70 authorized to prescribe buprenorphine, although Rossignol estimates the number is closer to 200.
Current regulations allow only 100 patients per doctor on medication assisted therapy (30 in the first year of approval), and all of the authorized physicians in New Hampshire have waiting lists.
There is evidence and a growing consensus in the medical community that drugs like buprenorphine, sold under the trade name Suboxone, can significantly reduce fatalities and other consequences of opioid addiction, when combined with regular counseling.
President Obama last fall told health-care providers across the country that access to medication-assisted treatment must be expanded, that federal agencies must identify barriers to medication-assisted therapy and remove them. The White House Office of National Drug Control Policy, for example, has announced that drug courts that bar addicts from receiving medication-assisted treatment will no longer receive federal funding.
A recent Huffington Post investigation found that the treatment industry continues to resist medication-assisted treatment, reporting that, “For decades, those treating opioid addiction have ignored the consensus that the best approach involved medications approved by the Food and Drug Administration, coupled with counseling. Instead, the treatment industry insisted on a model known as abstinence, in which any prescription medication aimed at addressing a patient’s opioid use disorder was forbidden.”
Buprenorphine, a synthetic opioid, binds to and partially activates opioid receptors. It’s long-acting and provides steady blood levels that do not create euphoria, while preventing withdrawal symptoms or cravings caused by low blood levels. Unlike methadone, it is not intoxicating.
In a recent roundtable discussion with the Union Leader, board members of the N.H. Alcohol and Drug Abuse Counselors Association were unanimous in their belief that the state is desperate for more doctors to obtain the federal waiver needed to prescribe drugs like buprenorphine, which requires only about six to eight hours of online training for a licensed MD or OD.
Doctors are well aware of the need. In January, Rossignol and three like-minded physicians worked together with state officials to create what they called a “guidance document on best practices for delivering community-based, medication-assisted treatment for opioid disorders.”
“I have hope that more of the medical community will step forward to care for patients that are in the throes of this disease,” said Rossignol, who is now affiliated with the Concord Hospital Family Health Center.
On the sidelines
What has kept doctors on the sidelines? Rossignol is nuanced in her answer.
“It goes along with the stigma associated with this disease,” she said, “and the thought that every patient that has this disease of addiction is somehow going to be disruptive, going to cause the staff a lot of stress, going to be difficult to deal with.”
Dr. Terry Bennett, a private practitioner in Rochester for 25 years, has been prescribing Suboxone to his patients under a federal waiver for the past five years. He quickly hit the 100-patient limit, and has been dealing with a waiting list ever since.
He is more blunt in his assessment of why so few doctors obtain the waiver.
“They’re afraid the rest of their practice will depart,” he said. “I was, when I first took this up. I was worried that my Suboxone patients would interfere with the rest of my practice, so we started by isolating them at the back of the clinic, because the assumption is that you are dealing with thieves, liars and hookers.”
Addiction is not a character flaw, Bennett said. It is a disease with a genetic component like many others, and should be treated just as we would treat diabetes or any other chronic disease. “If you can’t cure it, at least you can treat it successfully,” he says.
Stemming the tide
Only 30 percent of treatment programs in the state offer medication for opioid use disorders, according to the “best practices” manual that Rossignol helped draft.
Expanding access to such programs will require more certified doctors, more counselors to work with them and pressure from federal and state authorities to lower the price of generic buprenorphine. Bennett said a buprenorphine regimen can cost $300 to $400 a month, including the cost of the drugs, labs and office visit.
If we can’t end the addiction crisis in the short term, at least we can stem the tide of fatalities, says Charles Bussison, a master’s level counselor and board member of the N.H. Alcohol and Drug Abuse Counselors Association.
“These medically assisted treatments are vital,” he said. “They’ve shown in other countries like France and the Netherlands — and also in Baltimore — when they started complementing behavioral therapy with medically assisted treatment, the fatality rate dropped by 30 percent.”