2023 Namey/Burnett Preventive Medicine Writing Award author Briana Saravanabavanandhan advocates for greater access to medication-assisted treatment for patients with opioid use disorder.
Briana Saravanabavanandhan, 2023 Namey/Burnett Preventive Medicine Writing Award Submission
Sponsored by the ACOFP Foundation, with winners selected by the ACOFP Health & Wellness Committee, the Namey/Burnett Preventive Medicine Writing Award honors the memory of Joseph J. Namey, DO, FACOFP, and John H. Burnett, DO, FACOFP—dedicated advocates for osteopathic medicine—and recognizes the best preventive medicine blog posts submitted by osteopathic family medicine students and residents.
“If all the patients in your clinic love you . . . you’re probably handing out too many narcotics. It’s healthy not to be liked by every patient.”
Dr. Michael Brown, DO, a family medicine practitioner in Smithville, MO, presented this pearl of wisdom to me on my first clinical rotation in medical school. I spent four weeks learning about community health from Dr. Brown, who emphasized the importance of providing patient care with integrity. It was not surprising to learn that Dr. Brown accepted patients struggling with opioid use disorder (OUD), given how prevalent addiction is in our country. However, I came to learn that not all primary care doctors provide addiction care. It is more of a choice.
While Smithville has a population of about 10,552, it is about 16 miles away from the heart of Kansas City, which is not a care desert.17 Yet for addiction care, Dr. Brown stated, “I’m one of three or so physicians in the Kansas City region who accepts and manages patients with [opioid] addiction.” Interestingly, providers from any specialty, not just primary care, can serve patients working through recovery or active opioid addiction. All it takes is the right training.
In 1969, President Nixon tasked his Attorney General to consolidate all the federal drug laws into one statute to clarify, expand, and target federal regulation of drugs with abuse potential.16 In 1971, the Controlled Substances Act (CSA) was created to help prevent drug abuse and dependence by fortifying U.S. law enforcement’s authority with drug abuse.18 The Drug Enforcement Administration (DEA) was created in 1973 as the government’s authoritative body to enforce federal drug laws.4 The CSA established five schedules for controlled substances to be placed depending on their potential for abuse and addiction, accepted medical use, and safety.18
Currently, the FDA approves three medications for OUD: methadone, buprenorphine, and naltrexone.3 Methadone, a schedule II drug, was the first approved medication to use as treatment for OUD in 1974.5 In the 1970s, that a legal opioid (i.e., methadone) with severe potential for abuse and addiction could be used as treatment for illicit opioid use (e.g., heroin) created a large amount of stigma around OUD treatment.4 To counter this, the FDA created the phrase “methadone-assisted treatment” or “MAT” to emphasize the neurobiological nature of addiction and medical basis of OUD treatment.3,11 Since then, other controlled substances, medications with potential for abuse and addiction, have been approved by the FDA for effective treatment of not only OUD but also alcoholism.11 As such, MAT no longer stands for “methadone-assisted therapy” but rather “medication-assisted treatment.”11
When providers refer to having a “MAT” patient, that does not necessarily mean the patient is on methadone. In fact, a regulation from 1974, which is still in place today, requires methadone to be dispersed from “medication units” that are organizationally separate from systems of general medical care.18 Despite multiple medical studies showing the feasibility and safety of methadone dispensing for OUD in primary care clinics, the regulation given its schedule classification from the 1970s remains the same.2,19 Consequently, methadone cannot be dispensed from primary care clinics, which would help make treatment for OUD more accessible to a greater number of people in need.8 Patients adversely affected by this outdated regulation currently restricting methadone dispensing include those that are pregnant, who face a 50% increased risk in maternal death and life-threatening health issues.10
In the 1970s, the regulation of methadone as a schedule II drug made it possible for people with OUD to get treatment in the first place, as it was the only FDA-approved drug available.18 However, in the mid 2000s, Buprenorphine and Naltrexone were created, and FDA approved them for OUD treatment as well.1,9 Since Naltrexone is an opioid antagonist, it is not a controlled substance, and any licensed prescriber can dispense it with no additional training needed.9 Buprenorphine, on the other hand, is a schedule III drug which was restricted for dispensing in primary care settings until the Drug Addiction Treatment Act of 2000 (DATA 2000).1 Today, a waiver certification and official training are needed to prescribe Buprenorphine in primary care settings.1 Because of this, Buprenorphine and Naltrexone are far more accessible than methadone.1,9
Even with these changes, medical providers are reluctant to provide MAT.6,12 In 2019, rural physicians were surveyed about their attitudes and perceptions about providing MAT.6 The physicians reported fear of DEA intrusion into their practice, paucity of mentorship, and potential misuse of medications as reasons to abstain from pursuing buprenorphine dispensing rights and providing MAT.6 This is alarming and disappointing given that research shows MAT decreases the use of illicit drugs and serves to make our communities safer by decreasing criminal activity among patients with substance abuse disorders.10,11,13
MAT has improved patient survival, increased treatment retention, and decreased relapse potential.10,11 This translates to fewer hospital beds being filled with patients struggling with opioid or alcohol use and greater availability of medical personnel for other acute issues. Second, mothers with substance use disorder on MAT have been shown to have improved birth outcomes.10,11,12 This helps decrease demand on pediatric ICUs, which can be crucial during peak viral seasons. Furthermore, MAT helps lower patient risk of acquiring comorbid conditions such as HIV and viral hepatitis.10,11,12 As if these foundational gains were not benefit enough, Dr. Brown alone has seen children gain their parents back, young adults keep themselves alive to see the promise of their future, and others achieve meaningful employment as they show up for their families.11 All this good due to their access of MAT.10,11,12,13
The promise of addiction care through primary care and other specialties has already been realized by so many patients lucky enough to have a provider willing to work with them. Hopefully learning about the history, effectiveness, and ethical benefits of MAT inspires those who can provide MAT to do so and to advocate for the dispensing of methadone in primary care clinics as well.
- Buprenorphine (trade names: Buprenex®, Suboxone®, Subutex® , Zubsolv . . . (n.d.). Retrieved December 12, 2022, from https://www.deadiversion.usdoj.gov/drug_chem_info/buprenorphine.pdf
- Brooner RK, Stoller KB, Patel P, Wu LT, Yan H, Kidorf M. Opioid treatment program prescribing of methadone with community pharmacy dispensing: Pilot study of feasibility and acceptability. Drug Alcohol Depend Rep. 2022 Jun;3:100067. doi: 10.1016/j.dadr.2022.100067. Epub 2022 May 16. PMID: 35757566; PMCID:
- Center for Drug Evaluation and Research. (2019, February 14). Information about medication-assisted treatment. S. Food and Drug Administration. Retrieved December 12, 2022, from https://www.fda.gov/drugs/information-drug-class/information-about- medication-assisted-treatment-mat
- Drug Enforcement (2019). 1970 – 1975. Retrieved December 12, 2022, from http://www.deamuseum.org/dea_history_book/1970_1975.htm
- Drug Enforcement Administration, Drug Fact Sheet: Methadone1–1 (2022). https://dea.gov/sites/default/files/2020-06/Methadone-2020.pdf
- Deyo-Svendsen M, Cabrera Svendsen M, Walker J, Hodges A, Oldfather R, Mansukhani MP. Medication-Assisted Treatment for Opioid Use Disorder in a Rural Family Medicine Practice. Journal of Primary Care & Community Health. 2020;11. doi:10.1177/2150132720931720
- Fiellin DA, O’Connor PG, Chawarski M, Pakes JP, Pantalon MV, Schottenfeld RS. Methadone maintenance in primary care: a randomized controlled trial. JAMA 2001;286:1724-1731.
- Knudsen HK, Abraham AJ, Oser CB. Barriers to the implementation of medication- assisted treatment for substance use disorders: the importance of funding policies and medical infrastructure. Eval Program Plann. 2011;34(4):375-381. doi:10.1016/j.evalprogplan.2011.02.004
- Naltrexone. SAMHSA. (n.d.). Retrieved December 12, 2022, from https://samhsa.gov/medication-assisted-treatment/medications-counseling-related- conditions/naltrexone
- McCarthy, John J. MD; Jones, Hendree E. PhD; Terplan, Mishka MD; Rudolf, Vania P. MD; von Klimo, Melinda Campopiano MD. Changing Outdated Methadone Regulations That Harm Pregnant Patients. Journal of Addiction Medicine: March/April 2021, Volume 15, Issue 2, p 93-95 doi: 10.1097/ADM.0000000000000720
- Medication-assisted treatment (MAT). (2022, July 25). Retrieved December 12, 2022, from https://www.samhsa.gov/medication-assisted-treatment
- Merrill JO, Jackson TR, Schulman BA, et Methadone medical maintenance in primary care: an implementation evaluation. J Gen Intern Med 2005;20:344-349
- Relative effectiveness of integrating MAT in substance abuse specialty programs vs primary care settings; and business models that make integration into primary care more attractive to more providers. Content last reviewed November 2017. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD
- Saah T. The evolutionary origins and significance of drug addiction. Harm Reduct J. 2005;2:8. Published 2005 Jun 29. doi:10.1186/1477-7517-2-8
- Samet, J. H., et al. (2018). “Methadone in Primary Care — One Small Step for Congress, One Giant Leap for Addiction Treatment.” New England Journal of Medicine 379(1): 7-8.
- Senate Committee of the Judiciary, & Mitchell, J. N., Statement of Attorney General John N. Mitchell1–19 (1969). Washington, DC; U.S. Government Publishing Office.
- Smithville Provider. Place Explorer – Data (2021). Retrieved December 12, 2022, from https://datacommons.org/place
- U.S. Government Publishing Office. Pub. L. 91–513, title II, § 101, Oct. 27, 1970, 84 Stat. 1242
- Wu LT, John WS, Morse ED, et al. Opioid treatment program and community pharmacy collaboration for methadone maintenance treatment: results from a feasibility clinical trial. Addiction. 2022;117(2):444-456. doi:10.1111/add.15641