By Joshua M. Sharfstein, MD, and Yngvild Olsen, MD
With the opioid epidemic now claiming nearly 2000 lives from overdose in the United States each month, the medical profession is increasingly accepting the assessment of noted surgeon and writer Atul Gawande, MD: “We started it.” Specialty societies such as the American Academy of Family Physicians and American College of Physicians are offering tools to reduce the unnecessary use of opioids for pain and the risk of addiction. The Federation of State Medical Boards has released guidelines for the treatment of chronic pain, and many state medical boards have adopted their own policies. Physicians are responding. Since peaking in 2012, opioid prescriptions have declined by more than one-fourth.
Avoiding future cases of opioid addiction, however, does little to address the harm that already exists. More than 2 million US residents now have an opioid use disorder. Yet the Surgeon General’s Report Facing Addiction in America found major gaps in access to effective treatment. The gaps go beyond financial and geographic barriers to include major quality concerns. In 2016, among those with opioid addiction who were able to receive specialty addiction care, only about 1 in 3 expected to receive treatment with medications. Yet it is the use of medications, particularly methadone and buprenorphine, that has the greatest potential to save lives. These treatments are associated with substantial reductions in the risk of death for individual patients and many fewer overdose fatalities at the population level.
Physician Training Needed
To save more lives from opioid addiction, physicians need training. That’s why we support a simple proposal: that the Accreditation Council on Graduate Medical Education (ACGME) require all residents in clinical specialties to take a course on the appropriate use of buprenorphine and other medications approved by the US Food and Drug Administration for the treatment of opioid addiction. This course is available for free. A second idea (put forward by Massachusetts addiction specialist Sarah Wakeman, MD) is for ACGME to require that all core faculty in these residency training programs apply for and receive the waiver needed to prescribe buprenorphine from the Substance Abuse and Mental Health Services Administration and the Drug Enforcement Administration.
To understand why these steps are necessary, some history is in order. For nearly as long as there have been challenges with opioids in the United States, there has been suspicion of doctors who provide treatment to people with addiction. As David Musto, MD, documented in The American Disease: Origins of Narcotic Control, in the early 20th century, physicians in such places as Jacksonville, Florida, and New York City set up clinics to provide a regular daily dose of morphine to patients and reported substantial improvement in their patients. However, the Harrison Act of 1914 led to a fierce crackdown on such treatment, with many physicians losing their licenses and even going to jail, accused of such charges as causing the “gratification of a diseased appetite for these pernicious drugs.”
The Harrison Act’s long shadow explains why the federal government regulates the use of opioid medicines for addiction treatment far more aggressively than use of these very same medicines for pain. After methadone was developed in the 1960s as a treatment for opioid addiction, the US Congress and then the Drug Enforcement Administration (DEA) established strict requirements for treatment programs with specific instructions for prescribing, dispensing, record keeping, and security. These restrictions do not apply to the use of methadone for pain, even though its use for pain has been associated with increased rates of death.
In 2000, Congress applied stringent controls to the use of buprenorphine for addiction treatment—even though this medication, as a result of its pharmacology, poses much less of a risk of overdose compared with other opioid medications including methadone. The restrictions included limits on the number of patients that an office-based physician can treat, as well as a legal requirement to pass an 8-hour training course before using buprenorphine to treat opioid addiction.
Today, there remains an enormous stigma towards lifesaving medications for opioid use disorder. Only about 6% of approximately 1 million physicians in the United States have taken the required training for prescribing buprenorphine. In nearly half of US counties, there is not a single physician authorized to prescribe buprenorphine. In 38 states, more than 3 in 4 programs that provide methadone operate at near capacity. And even though taxpayers spend more than $10 billion a year through the Medicare program to support graduate medical training, about two-thirds of training programs do not support training in prescribing buprenorphine.
Enter ACGME. Recently, the organization added a general requirement to take effect on July 1, 2019, calling on all residency programs to “provide instruction and experience in pain management for the specialty, including the recognition of the signs of addiction.” In response to questions, the ACGME has said that additional proposals, including adding a requirement for training in the treatment of addiction, will be considered at upcoming meetings. Such a step would be most welcome to a group of medical students and physicians, who wrote to the ACGME, “Imagine if the disease at hand were diabetes. If there were enormous gaps in access to insulin, with thousands of untrained physicians, there would be a national imperative to assure adequate training. We believe the same call to action should apply for opioid use disorder.”
There are certainly alternative approaches to increasing the number of physicians who can prescribe effective treatment with medications. Congress could get rid of the training requirement. Or the DEA could make the training a mandatory part of the registration process to prescribe controlled substances. Or the Centers for Medicare & Medicaid Services could require the training to be completed by residents as a condition for institutions to receive funding for graduate medical education.
It is also true that physician training alone will not immediately translate into greater access to treatment everywhere. What’s more, treatment expansions should be paired with other major investments to address distress and inequity.
Yet these are not reasons for inaction. By educating and empowering young physicians, the ACGME can stimulate advocacy for higher reimbursement, more effective models of care, investments in prevention, and less stigma towards addiction and its treatment.
It hard to think of a more apt way for the medical profession to make amends for its role in a crisis that has led to a decline in US life expectancy over the last 3 years. With leadership by the ACGME, the medical profession can take a big step towards being able to say, “We ended it.”
About the authors:
Joshua M. Sharfstein, MD, is Vice Dean for Public Health Practice and Community Engagement at the Johns Hopkins Bloomberg School of Public Health. He previously served as Secretary of the Maryland Department of Health and Mental Hygiene, as the Principal Deputy Commissioner of the US Food and Drug Administration, and as Commissioner of Health for Baltimore. He is also a consultant to Audacious Inquiry and to Sachs Policy Group. A pediatrician, he lives with his family in Baltimore. (Image: Chris Hartlove)
Yngvild Olsen, MD is the medical director of the Institutes for Behavior Resources, Inc, an addiction treatment program in Baltimore, Maryland. She becomes the vice president of the American Society of Addiction Medicine in April 2019, and is the coauthor, with Dr Joshua Sharfstein, of The Opioid Epidemic: What Everyone Needs to Know, to be published this Spring from Oxford University Press. (Image: American Society of Addiction Medicine)
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