September 18, 2019

A Pathway to Recovery Begins at the Primary Care Office

Christian* was fourteen when he broke his back in a sledding accident in the mid-1990’s. Only able to partially recover, his doctors prescribed pain medication – opioids – to help manage his ongoing symptoms. When he aged out of his health insurance at eighteen, he realized he couldn’t get by without the pills. “I was addicted to something and didn’t even really know what addiction was,” he says. “I didn’t just decide to pick up heroin one day; I worked up to it.”

For almost two decades, Christian struggled through cycles of attempted sobriety, relapse into drug use, and a progression to increasingly stronger substances. Last year he walked into his North Shore Physicians Group (NSPG) primary care office, part of Partners HealthCare, committed to trying to stop using for good. His reason to seek treatment again, after it had failed so many times—

“I didn’t want to lose my wife.”

LAYING STEPPING STONES IN PRIMARY CARE PRACTICES

Dr. Norma Lopez, DO, Medical Director for the NSPG Recovery Support Program and a family practice physician by training, has been specializing in treatment for substance use disorders (SUDs) since 2006. Her office is in the back of Lynn’s Union Hospital just beyond a winding garden path overflowing with flowers, meditation benches, and a trickling stream filled with Koi fish bigger than footballs. It’s an inviting place to walk through for anyone starting a journey to sobriety.

Dr. Lopez focuses on two types of conditions—alcohol use disorder and opioid use disorder. Even though the opioid crisis has dominated public interest in recent years, she stresses that treatment for alcohol use disorder is just as important.

“Sometimes alcohol use gets overshadowed because everyone is focused on opioid use and they forget that there are other substances that patients can get addicted to,” she says.

Usually, patients are referred to her through their primary care office. Every primary care office in the North Shore Physicians Group has an embedded social worker, and they are usually the ones who connect patients to Dr. Lopez. As a tangential arm of the embedded social worker model, North Shore also employs unique team members called Recovery Coaches. These individuals have dealt with substance use disorders themselves and offer invaluable peer support and care coordination for patients during their journey.

Deidra Smith-Horton, Richard Zombeck, and Dr. Norma Lopez

“For the last ten years, the primary care providers have gotten used to referring patients with mental health or substance use disorder issues to the social workers. But as a social worker you’re like gosh, I need resources for this,” says Deidra Smith-Horton, LICSW, Behavioral Health Program Manager for NSPG. “When we tied the recovery coaches into our work there wasn’t any hesitancy from the rest of the primary care team. It was a pretty easy transition.”

When NSPG’s first recovery coach, Richard Zombeck, started in 2017 he received 95 referrals in the first two months. It had ballooned to about 240 referrals within the first six months.

“I think in the past if a patient showed signs of a substance use problem, there was trepidation from providers about even asking them about it because there was no solution,” says Zombeck, who is both a recovery coach and the Peer Support Supervisor at NSPG. “Your options were: why don’t you go to Alcoholics or Narcotics Anonymous, or let’s see if we can get you a therapist. Now, the providers are able to actually do something.”

MORE THAN A MEDICATION  

Christian was referred to Dr. Lopez and Steve Lesnikoski, another NSPG recovery coach, through the social worker at his primary care office.

“Steve made going through all this stuff a lot easier. He’s just been somebody who I know is there to talk to no matter what and whenever,” says Christian.

Once Christian met with Dr. Lopez, she suggested he try Suboxone® (buprenorphine/naloxone). This pharmaceutical helps curb physical cravings for opioids and can help wean patients off opioid dependency. Physicians, Nurse Practitioners (NP’s), and Physician’s Assistants (PA’s) require a waiver from the DEA to prescribe it. But unlike methadone treatment, which must be performed in a highly structured environment, bupenorphine/naloxone can be prescribed and dispensed by a waivered provider in their own office, significantly increasing treatment access.

“I can still function, barely,” says Christian. “The Suboxone® doesn’t relieve my pain, but it makes it so that my craving for any opiate is gone. I haven’t had an opiate in a long time.”

Dr. Lopez offers another medication used for both opioid and alcohol-use disorders called naltrexone, more commonly referred to by the brand name Vivitrol®, which is the injectable form of naltrexone. While no special license is needed to prescribe Vivitrol®, the patient does need to be seen once a month for injections. Dr. Lopez notes that these are just two of the common medications she prescribes and that there are other options available.

Medications can be one important component of treatment, but patients also have access to a wide variety of treatment options—detox programs, sober homes, outpatient therapy, peer support groups, and more. Zombeck has compiled many of them in an online resource guide he shares with his patients, other recovery coaches, and clinicians.

“We try to treat each patient as an individual,” says Dr. Lopez. “Everyone’s story is different and everyone’s needs are different. We try to meet them where they’re at. But the more supports they have, the more likely their longer-term sobriety.”

RAISING AWARENESS FOR FELLOW PHYSICIANS

While Dr. Lopez has honed her skills treating opioid and alcohol use disorders, her larger goal is to help providers feel comfortable caring for their patients themselves.

“Patients feel more comfortable getting treated where they get their primary care,” she says. “We’re trying to encourage primary care providers to realize that this can be done at an office visit. They already see these patients, and the patients and their families are more comfortable with them because of that established relationship.”

The key thing, she explains, is helping providers feel capable of treating this population, showing them the supports they have available to them, and reminding them that are not alone in the process.

That shift requires a lot of training hours. Dr. Lopez has been working with the nurses on the administrative process for ordering Vivitrol® injections and having trainers come down to educate the nurses on how to properly administer the medication. She also does the Medication Assisted Treatment (MAT)  waiver trainings, which include a four hour in-person training and four hours of online modules for physicians. PA’s and NP’s require 24 hours of total training. So far, she has trained 78 providers, which include primary care providers, hospitalists, and ER providers with more training sessions to come.

“I think the program is very young and there is still a lot of work still to be done,” says Dr. Lopez. “But I’m very happy with what we’ve done so far.”

Others across the Partners HealthCare system offer waiver trainings, including Massachusetts General Hospital, Brigham and Women’s Hospital, and the Partners HealthCare Population Health team—who have trained well over 1,000 physicians and clinical staff. Dr. Lopez is quick to say though, that getting physicians waivered is just the first step in the process. She works with providers and staff to make sure they feel confident in treating these stigmatized patients on their own.

“Part of my job is to try and break down those barriers. You try and make them realize that substance use disorder is a chronic disease and is not that much different than treating hypertension or diabetes,” she says.

A NEW FOCUS

Christian with his wife and daughter

Christian is glad he was able to easily seek help right at his primary care office and get connected with Dr. Lopez. He says he felt “on-edge,” for about a year, but has just recently felt more comfortable and stable. He’s been busy taking care of his newborn daughter and helping his wife out with her pet-care business.

“Dr. Lopez, she was really nice from day one to now. She’s been pretty supportive and has kept me on track,” he says. He’s also been a big fan of the recovery coaches.

“I’ve done recovery before the coaches and I’ve done recovery after the coaches. It’s a huge step in the right direction,” he says. “It’s all about mental health. You know? Just the stuff people go through. They need somebody, anybody, even if it’s just somebody to talk to. And that’s what having Steve to talk to has kind of been like; it’s been pretty huge.”

Christian has one piece of advice for those out there struggling with substance use. He says, “Just listen to the people that are there to help you. That was new for me, people actually being there to help you.”


*Only first names are used to protect patient privacy.

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