{"id":502,"date":"2016-04-13T19:27:16","date_gmt":"2016-04-13T19:27:16","guid":{"rendered":"http:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/?p=502"},"modified":"2016-12-14T19:53:23","modified_gmt":"2016-12-14T19:53:23","slug":"how-do-you-treat-an-epidemic","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/2016\/04\/13\/how-do-you-treat-an-epidemic\/","title":{"rendered":"How Do You Treat an Epidemic?"},"content":{"rendered":"

\"Elizabeth

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Elizabeth Donahue, RN, MSN, NP-C, practices adult primary care medicine in Boston, MA.<\/p>\n

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<\/p><\/div>I have been in my current clinical role \u2014 an NP primary care provider carrying my own panel \u2014 for almost a year now. Opening a new practice and introducing such a role has many challenges; one of these is the influx of new patients \u2014 specifically, obtaining histories and making treatment decisions for patients whose medical histories are unknown except for what they report.<\/p>\n

A few weeks ago, I met my fourth new patient of the day, a man transferring care from out of state and needing refills on all of his current medications. That list happened to include suboxone for the simultaneous treatment of the chronic pain he experienced from a remote traumatic brain injury and the substance use disorder he suffered as a result of treating that pain with opioids for years. Because he had been receiving his medication from his former out-of-state provider for the nearly two months it had taken him to find a primary care provider in Massachusetts (see my previous thoughts on that topic here<\/a>), he was due for refill on his suboxone within a week of his visit with me. Herein lies a major problem: I want to be able to provide this essential treatment for this patient and so many like him, but as a nurse practitioner, I cannot obtain a DEA X license that would allow me to do so. And even in a well-resourced state like Massachusetts, I fear that this patient will face barriers to continuing his treatment and may relapse.<\/p>\n

Despite this hurdle, I was feeling optimistic about my ability to care for this man and others going forward because I was signed up for a health policy workshop dedicated to learning about the opioid crisis and how clinicians can understand the trends and \u201cbend the curve.\u201d Arriving at the workshop, I sat down eager to learn and soon found myself stunned by the breadth and depth of the opioid abuse epidemic. I also felt a bit irresponsible that I hadn\u2019t educated myself earlier and gotten involved sooner. So here\u2019s what I learned, and how I hope all clinicians can help.\"stateWithoutStigma\"<\/a><\/p>\n

We were welcomed by Dr. Monica Bharel, Commissioner of the MA Department of Public Health, who shared some information about the source of the problem. It was not surprising to learn that a great majority of substance use disorders start with the prescription of opioids. However, it was<\/em> surprising to hear that most of these opiate prescriptions in Massachusetts are initiated by primary care providers \u2014 not surgeons or specialists, but providers like me.<\/p>\n

Next, we heard about the scope of the problem based on some data from the CDC \u2014 how overdose deaths outnumbered traffic deaths in 31 states in 2010 (up from only 10 states in 2005). The statistics about how many people are suffering became even more overwhelming when I learned that the deaths only scratch the surface of how widespread the problem is. Each death is representative of approximately 32 ED visits for misuse\/abuse, and each death represents nearly 130 people who misuse opioids or suffer from opioid use disorder that has not yet escalated. Finally, we heard about shortcomings regarding current solutions to the issue: Only physicians can obtain a waiver to prescribe needed agonist medications to treat opioid use disorder, yet only 1\u20135% of physicians in each state have applied for and obtained the license needed to prescribe this life-saving treatment, and those physicians are limited to treating 30 to 100 patients. More surprising statistics from my own research included this: Only 50% of addiction treatment centers offer medications, and in those that do, only 38% of patients deemed in need of treatment are offered it.<\/p>\n

Thankfully, the speakers moved toward solutions that have already demonstrated success. And I was grateful to hear that there are a range of possible options \u2014 from those that can be implemented immediately (without too much pain for already overburdened primary care practices) to long-term solutions currently in the works. An NP colleague from the North Shore, Christine Malagrida, discussed how her practice uses screenings for alcohol use, drug use, and depression at all new patient appointments and annual physicals and then follows up with motivational interviewing techniques and suggestions\/resources for the patients who screened positive. Of course, it\u2019s important to know the resources in your area before implementing patient screening for substance use disorder, so that if you uncover an issue, you can direct your patient appropriately.<\/p>\n

One model practice initiative in Massachusetts was presented by Colleen LaBelle, a leader in substance use disorder work in Massachusetts and Director of Boston Medical Center\u2019s Office Based Opioid Treatment with Buprenorphine program. The program focuses on a collaborative teamwork model that supports physicians who prescribe agonist medications by providing patient care via nursing staff, case managers, social workers, and others who can address the many other physical and mental health concerns of patients undergoing treatment. This initiative has dramatically decreased ED visits and hospital admissions among those receiving treatment and has increased the number of patients receiving treatment from 0 to >8000 between 2007 and 2014. This type of initiative should be studied and replicated.<\/p>\n

\"pills-506222802\"<\/a>The most encouraging news was about two pieces of legislation that should dramatically increase access to medical treatment of opioid use disorder. The TREAT Act filed by MA Senator Markey would remove artificial barriers that currently limit the number of patients whom physicians can treat, thus allowing more patients to get the care they need from MD providers. President Obama also recently included a $1.1 billion budget line item dedicated to pilot projects that would extend DEA X waivers to nurse practitioners and physician assistants (in states that already have controlled substance prescriptive authority) in order to expand the numbers of prescribers who are able to treat patients needing suboxone for substance use disorder. Nearly 33% of NPs surveyed indicated that they would be willing to prescribe this type of medication. Also, projected growth of NPs and PAs by 2020 is 30% and 58%, respectively (compared to 8% for physicians), so this is a group with a demonstrated interest and growth rate to support a real-time increase in access to care for patients who need it.<\/p>\n

Inspired to change my practice by this incredibly informative and empowering workshop, I returned to my office the next day. My first patient arrived at clinic under the influence of heroin, which was reported to me by my medical assistant, who completed a routine screening on the patient as part of intake. I was glad to have at least the basics in place, to be asking the right questions, and also to have incredibly knowledgeable and compassionate staff with whom the patient felt comfortable being honest. The patient discussed with me that she has been using heroin daily for the last 4 months after her previous primary care doctor discontinued her prescription for oxycontin as treatment for her lower back pain and a neighbor offered her street drugs as a substitute. She expressed a sincere desire to stop using heroin and find a more appropriate treatment for her back pain, but also felt defeated at the stigma she had experienced at the hands of previous providers. (What could have reinforced the need for opioid abuse treatment to me better than this patient?) Thankful for the assistance of a social work colleague but cursing the delays in legislature and stigma surrounding this problem, I will do my best to care for her with the help of waivered physician colleagues as part of the team. In the meantime, I have signed up for the necessary training so that when the time comes when I can apply for a DEA X license, I will be ready. I hope that you, my provider colleagues, will consider it too.<\/p>\n

Below are sources of information on both the staggering statistics and available resources. Though I am by no means an expert on this topic, I now realize that the scope of the opioid abuse problem \u2014 which is now THE number one cause of preventable death in the U.S. \u2014 is far too large to stand back and watch someone else solve.<\/p>\n

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Practical resources for providers: <\/strong><\/p>\n

Information and Application for DATA Waiver (DEA X license to treat)<\/p>\n