Medication-Assisted Treatment Should Be Part of Every Family Physician’s Practice: No

I find the opinions of specialists who have not worked with Family Physicians are based on attitudes rather than experience. Family Physicians are most capable of managing addictions. They can manage the medical and psychiatric co-morbidities of addicts. We are specialists in listening, being accessible and managing multiple chronic conditions. Our training involves knowledge and use of community services. I have chosen recently to work full time in a rural psychiatric facility. I am a physician prescriber for the clinic, am a resource for the mobile crisis team, am a co-provider for the inpatient unit, and am a prescriber for the substance abuse therapy groups. I am referred most of the psychiatric patients who also have serious medical illnesses, including brain injury or illness. I have psychiatrists easily available for consultation which has been blessedly true for most of my career. I have received many compliments from staff that it is convenient to have my medical expertise on site. The training for buprenorphine prescribing is similar to other medical pharmacology. A little support from peer counselors, psychiatry and social workers has oriented me quickly to the world of addicts and I have been very comfortable in my setting. My Suboxone patients are appreciative the stability that this medications brings to their broken lives.

Competing interests: None declared

In my experience, patients who seek buprenorphine treatment/are most appropriate patients for buprenorphine for their opiate use have a more severe stage of disease.

Using the DSM-5 criteria for Substance Use Disorder (SUD), patients may be separated into "mild, moderate or severe" depending on how many criteria are met. For example, someone with mild SUD might occasionally use a low dose of a low potency opioid, and might have received it initially from a provider for an acute pain indication. Such patients are employed, maintain a job and relationships and in general have few if any other psychosocial issues. Moderate SUD patients take higher potency opioids on a more regular/daily basis, might have withdrawal if they run out and have likely lost a job or two and have lost relationships from their use as well. Patients with severe disease use opioids throughout the day, often multiple times-to avoid severe withdrawal symptoms. They spend their time procuring the drug, have lost relationships/jobs, and steal, often from their own family, to support their habit. Their preferred route of administration has switched from oral to intranasal or IV and they have often experienced other negative health consequences from their use. So, the treatment plan we recommend is based on the stage of the disease, as well as the patient's unique mental health and physical history/condition and patient preference -but we certainly would not recommend buprenorphine as initial treatment to a patient with mild substance use disorder. Many times, counseling, frequent visits/urine testing, support from family/friends and if desired, AA/NA is enough to get mild stage disease patients back on track. Naltrexone/vivitrol may be indicated as well in some cases. So I disagree with Dr. Coffa's statement, "buprenorphine, methadone, and naltrexone should all be offered as choices for patients when they initially present to care". Rather, it is our duty as treatment specialists, to properly assess the level of disease and then to suggest a treatment plan tailored to meet the patient's unique needs and level of illness. This approach coincides more with Dr. Coffa's earlier view presented in the Am Fam Physician, 2013 Jul 15;88(2);113-121 article where she essentially stratifies patients into 3 categories of severity, each calling for a different level of intervention, (using DSM IV TR criteria). In this article, Dr. Coffa states, "After a positive screening, a brief assessment should be performed to stratify patients into three categories: hazardous use, substance abuse, or substance dependence. Patients with hazardous use benefit from brief counseling by a physician. For patients with substance abuse, brief counseling is also indicated, with the addition of more intensive ongoing follow-up and reevaluation. In patients with substance dependence, best practices include a combination of counseling, referral to specialty treatment, and pharmacotherapy (e.g., drug tapering, naltrexone, buprenorphine, methadone)".

I would also like to address Dr. Coffa's statement, "it would be medically inappropriate to require that people try and fail therapies that typically do not work before they are given access to [buprenorphine]". I couldn't agree more. Perhaps my statement was misunderstood. What I stated is the following; "Patients requiring B/BN have exhausted/failed all other forms of treatment intervention including abstinence efforts and AA/NA/sponsors, other non-agonist pharmacotherapies, addiction counseling, intensive outpatient treatment, partial hospitalization, residential programs and other forms of rehabilitation, perhaps even court-ordered treatment with mandatory accountability and urine tox-screen assessments". Not that we require them to have failed the interventions before being offered MAT but rather that most have already been through these treatments by the time they arrive at our door. Again in my experience (5 years as staff psychiatrist at large urban FQHC), most patients who end up on agonist therapy have already been through many of the above treatments and so are likely to have a moderate to severe substance use disorder. It is possible that folks at more rural or more socioeconomically advantaged areas might present with moderate disease without having progressed through multiple other treatments, but this has not been our experience.

Dr. Coffa comments, "Dr Hill also argues that people with substance use disorder have too much co-morbid psychiatric illness to fit into the family medicine scope of practice". Again, perhaps some clarification will help. Since we see patients who have more severe stages of opiate use disorders, they often will have more severe co-morbid psychiatric illness (see references from original article). Psychiatry at our FQHC is integrated and co-located. Providers often refer their patients with more severe mental health issues to see psychiatry-and so they are likely to feel the same or greater need to refer to psychiatry when such patients are afflicted with a co-occurring opiate use disorder as well. Much depends on where you are treating patients-inner city, urban centers will be populated with more severe illness and will require more specialist care while suburban/rural centers may see more mild illness that can be handled by PCP's alone.

For 18 years before transitioning to an FQHC, I served as medical director for an urban community mental health center where dual diagnosis (substance use and mental illness) was the focus. I worked closely with others at the agency and with the local mental health board to develop a Suboxone clinic for our patients-one that ran for several years until funding issues impacted our ability to continue our clinic. The patients in this clinic were a fairly severely ill population, and as I reflect back on the effort, this clinic, while comprised of only 30 or so patients, required significantly more support staff/CPST help and doctor time than any of us would have anticipated at the outset. This experience, in part, compelled me to share a counterpoint view when considering the impact such intensive care might have on our already overburdened primary care workforce.

That said, there are no doubt many medical centers with providers that will be able to effectively handle mild to moderate opiate use disorders using MAT/other interventions, but I fear that in more urban centers where the disease burden is highest, the best-intentioned PCP's, even those trained to handle more routine mental health problems such as Dr. Coffa's residents, may find their already over-filled schedules, increasingly complex case-loads and brief appointment times made even more difficult to negotiate when even a few of the more severely ill dual diagnosis patients are added to their caseload.

Dr. Coffa states, "It is time to Embrace our Role", stating that "substance use disorder treatment is a natural extension of our scope". It has been my experience that primary care providers always have the best interests of their patients at heart, and work tirelessly to meet their needs. But if primary care is too willing to "embrace" the opiate crisis with open arms, they may find that they have taken on more than they can accommodate with current staffing levels. Such an awareness might fuel efforts to pursue increased financial resources from the government to support the increased work. Such resources are needed to support increases in staffing, programming and specialty services that will be necessary to properly address the complexity of this disease.

Competing interests: None declared