Geographic and Specialty Distribution of US Physicians Trained to Treat Opioid Use Disorder

The epidemic of opioid-related illness is well-described by Rosenblatt et al. [1] Rosenblatt and colleagues focused on the availability of the harm-reduction strategy buprenorphine-naloxone in rural communities. Their analysis of nationwide data bases of physicians uncovered some interesting findings. First, older physicians (ages 55-64) were much more likely to have waivers to have a buprenorphine waiver than younger physicians, perhaps suggesting a desire of older physicians to pursue more limited niche practices. Large disparities from state to state in the percent of physicians with buprenorphine waivers were also found, with many counties in the Midwest not having any physicians with buprenorphine waivers.

This analysis highlights the dearth of physicians in rural communities. The study also demonstrates that psychiatrists and rehab physicians are much more likely to obtain buprenorphine waivers than their primary care counterparts. Since specialists are less likely to practice in rural remote regions, this tendency exacerbates access issues in rural communities. However, the study found that the percentage of physicians in the smallest and most remote counties who had buprenorphine waivers was slightly greater than the percentage of physicians who practiced in the smallest and most remote counties when compared to all American physicians (1.3% with buprenorphine waivers vs .9% practicing in small remote counties), suggesting that the challenge in these counties is at least partially related to the broader issue of rural clinician shortages.

What do we do with this information? The dramatic geographic differences in counties with physicians with buprenorphine waivers suggest that education and outreach efforts with physicians are particularly important in the Midwest. Opportunities to streamline and mainstream prescribing of buprenorphine should be explored to encourage more primary care physicians to participate. Meanwhile, we must continue to address the overprescribing of opioids that has led to the current epidemic. If a patient complaint of pain is enough to get a prescription for opioids, we will continue to fight an uphill battle. Insisting that there be objective evidence of disease that is severe enough to justify the risks of overdose, addiction, misuse, and abuse associated with opioids would be a good place to start.

1. Rosenblatt RA, Andrilla CA, Catlin M, Larson EH. Geographic and specialty distribution of physicians trained to provide office-based treatment of opioid use disorder in the United States. Ann Fam Med. 2015;13(1):23-26

Competing interests: None declared

The late Dr. Roger Rosenblatt's illuminating article casts a spotlight on the starkly limited access to a highly effective treatment - buprenorphine - for addressing twin national epidemics - opioid addiction and opioid overdose deaths. His statistics are grim, yet they understate the problem. The article's map shows that almost all of Washington State has waivered buprenorphine prescribers, yet prescribers here know that many patients drive long distances from counties in our state where there currently is no access.

Overcoming the multiple barriers limiting access will require a large, coordinated effort at the national level. One approach is to awaken the "sleeping giant" of the AAFP membership, the largest group of physicians in rural regions of the United States. The AAFP has been silent so far on the prescribing of buprenorphine for addiction treatment by family physicians. Perhaps that will soon change.

In Thurston, Mason and King Counties we are currently preparing a buprenorphine resolution to bring to the state chapter and ultimately to the AAFP Congress of Delegates, in honor of Dr. Roger Rosenblatt, who so strongly championed this lifesaving treatment. The resolution would direct the AAFP to apply its credibility and resources to promoting buprenorphine as a mainstream part of family practice, and to train its membership to prescribe it. We hope we will find support for this resolution among family physicians across the country, so we can expand the ranks of our hardy community of current prescribers who understand these urgent problems and one of their important solutions.

Competing interests: None declared

I am a Family Physician, and the director of a Community Health Center serving two large rural counties in the center of Washington State. I am a Suboxone prescriber. I have caused as much addiction as I have treated.

Dr. Rosenblatt's study highlights yet another crisis in access to healthcare outside our large cities: rural practitioners lack competence in addiction medicine. While obtaining a DATA waiver to prescribe Suboxone is easy enough, that alone an Addictologist does not make. Expertise in the recognition and management of chemical dependency is critically important in any rural practice, and arguably to the future of all primary care. (We have cured almost everything else.) Yet I don't recall any formal training in chemical dependency in my medical school or residency (both of whom lauded themselves as our country's foremost training grounds for rural primary care.)

I challenge my academic colleagues to pick up the banner of increased competency in chemical dependency, as doctors Rosenblatt, Sullivan, and Gianutsos have done, and wave it high. Graduating Family Medicine residents should be as comfortable managing addiction as they are managing diabetes.

Also, I would caution readers not to conflate the use of Suboxone in the management of opioid dependence, with the use of Suboxone in the management of complex opioid dependency secondary to chronic pain. Whereas we have solid evidence supporting the safety and effectiveness of Suboxone in the former, we have very little evidence to support its use in the latter. Despite our best intentions and desire to help our patients who suffer from chronic pain, we are all complicit in our current opioid epidemic. Thus we are justifiably tempted to jump to Suboxone (buprenorphine) as a way out of our current pain crisis. Just as we did NOT have good evidence justifying our expanded use of opioids in the management of chronic pain in the 1990's; we do not have good evidence justifying our expanded use of buprenorphine in the management of chronic pain today.

We must be brutally honest with our patients and with ourselves that we are using buprenorphine to manage opioid dependence and NOT to manage chronic pain, even when both coexist within the same patient.

Malcolm Butler MD, Medical Director, Columbia Valley Community Health, Wenatchee, WA

Competing interests: None declared

While I have no problems with the authors' data, I think we are missing the big picture here. The opioid epidemic, which has become a prescribed medication epidemic, is an exceedingly complex phenomena, and is unlikely to be resolved with the treatment offered. Pushing the responsibility of managing this mess in the laps of Primary Care Physicians is inappropriate and ludicrous. The cause of this entire debacle lies with an out of control pharmaceutical industry that has pushed the use of opioid analgesics and a demand of patients to have their pain problems treated with these drugs. There has been no reasonable attempt to have these patients treated in a multidisciplinary fashion despite the evidence that shows this works, because insurance companies do not reimburse that type of treatment. The result has been patients desperate to have their pain treated end up in the offices of primary care physicians who have no resources other than prescription opioids to offer their patients. Inadequate assistance from pain specialists, few addiction specialists to turn to, and an inadequate plan to use more prescription opioids to solve the problem. In my opinion the problem is not the lack of primary care physicians willing to participate in this failed plan, but rather the lack of understanding by those who support it of the nature of the problem, and the actual practice of primary care.

Competing interests: None declared

The article by Dr Rosenblatt, et al, (1) helps highlights a fundamental barrier to patients attempting to access treatment for opiate use disorders: the lack of treatment availability. As the article illustrates, this is especially problematic in rural areas of the country.

We are facing an epidemic of opioid misuse (2) and mortality with over 16,000 deaths for the last full year reported. (3) Opioid prescribing has had the most significant impact on the increased mortality rate (4) and family medicine physicians have been responsible for a significant portion of that prescribing.(5) Family medicine educators have a responsibility to society to train physicians who practice evidence-based, safe and effective care. Buprenorphine is unquestionably the most effective therapy available for the treatment of opiate dependence in primary care. It is incumbent upon us to train physicians to treat opiate dependence (and other substance use disorders). To not provide this training is a disservice to those we train and to society.

Louis Paul Gianutsos, MD, MPH, Program Director, Swedish Family Medicine Residency Cherry Hill; Clinical Associate Professor of Family Medicine, University of Washington, 550 16th Ave, Suite 100, Seattle, WA 98122

1. Rosenblatt RA, Andrilla CHA, Catlin M, Larson EH. Geographic and Specialty Distribution of US Physicians Trained to Treat Opioid Use Disorder. Ann Fam Med 2015;13:23-26.
2. Manchikanti L, Fellows B, Ailinani H, Pampati V. Therapeutic use, abuse, and nonmedical use of opioids: a ten-year perspective. Pain Physician. 2010 Sep-Oct;13(5):401-35.
3. MMWR. Vital Signs: Overdoses of Prescription Opioid Pain Relievers, United States, 1999-2008. November 4, 2011;60(43):1487-1492.
4. CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers--United States, 1999-2008. MMWR 2011;60:1-6.
5. Volkow ND, McLellan TA, Cotto JH, Karithanom M, Weiss SRB. Characteristics of opioid prescriptions in 2009. JAMA 2011;305(13):1299-1301.

Competing interests: None declared

Physicians have the same beliefs and views as non-physicians. Residencies have few mentors treating addiction, few Medical schools have training for addiction. Physician mis-perceptions regarding addicted patients are the rule. Physician's are uncomfortable discussing drug addiction with patients in ways that will give patients hope. Often the same physician that prescribed the opiate which introduced and perpetuated the addiction are the first to dismiss that patient from the practice for abusing drugs. As physicians we have taken an oath to do no harm. The prescribing of opiates and other controlled substances must be accompanied by the ability to diagnose and treat the after effects of that treatment.

Competing interests: None declared