June 30, 2018

A Foothold on the Frontline: Support for Physicians Facing the Opioid Epidemic

Suboxone Waiver Training

Physicians participate in mentorship for support through the X-waiver process.

Ms. L had been her patient long enough for Dr. Provenzano to know the typical color of her blood sugar tracking diary, the sound of her laugh, and that Ms. L was always 10 minutes early. They had a relationship. One day, Ms. L came to her doctor for help – she had slipped back into opioid use. Although Ms. L wanted her to prescribe it herself, Dr. Provenzano was forced to refer her to a colleague to prescribe buprenorphine.

Buprenorphine is a medication for addiction used to help people reduce or quit their use of heroin or other opiates, like pain relievers. It is best known by the brand Suboxone®. Only after an eight-hour training can doctors prescribe it with a federal waiver. In a moving essay, Dr. Provenzano, a primary care physician at MGH Chelsea, reflects on Mrs. L’s case. This wasn’t a stranger, she had a personal investment in this patient—one she never would have guessed had a problem with substance use.

Unfortunately, the follow-up Dr. Provenzano assumed would happen, never did. It was both a personal and professional blow when she learned Ms. L had died of an overdose. In her essay, Dr. Provenzano confesses a major reason she didn’t have the waiver to prescribe buprenorphine was because she didn’t want to deal with patients who needed it. She knew people with substance use disorders (SUDs) were often very challenging and she was unsure how to meet their needs. She did not expect to encounter a patient like Ms. L, and then need to turn her away. What if she had treated her instead of a new doctor? Haunted by these thoughts, Dr. Provenzano committed to earning the waiver.

Support from the Partners HealthCare System

To help drive the call across Massachusetts for more certified clinicians, the Partners Center for Population Health has stepped up. Since September 2016, the Center, co-sponsored by the American Academy of Addiction Psychiatry (AAAP), has helped to promote and execute the “Half and Half” MAT Waiver Training which allows clinicians to prescribe buprenorphine. Half of the training is held live, in a classroom-style format, while the other half consists of self-paced online training modules. Enrolled providers complete up to 24 hours of training (depending on their credentials) and must pass a test at the end to earn their certificate of completion. With certification in hand, providers can apply for the government “X-Waiver” which allows them to prescribe buprenorphine for opioid use disorder (OUD). Through the continued support from the Center for Population Health, the number of authorized clinicians is rising across the Partners network. Since September 2016, 119 providers have been trained including 83 primary care providers.

Patients living with OUDs are living with a complex chronic condition; and in the same vein, their treatments need to encompass the whole picture. Often patients can have acute psychosocial needs that also must be addressed in their care.

“Providing support and training to providers is crucial so they feel equipped to address opioid use disorder as they would any other illness,” says Sarah Wakeman, MD, clinical lead for the Substance Use Disorder Initiative at Partners HealthCare.

NWH Physician MentorshipClinicians not only need support in obtaining waivers, but also in feeling prepared to treat all aspects of their patients. With this approach, SUDs patients are being looked at holistically. Their treatments are not separated from their primary care and trust between the patient and their PCP can continue.

“Primary care is often the first point of contact for the patient with substance use disorder. It can also be the last. Using the relationship between the PCP and the patient can serve as a key opportunity to start and continue therapy,” says Eric Weil, MD, Medical Director for Primary Care at Center for Population Health. “From personal experience, I can say with confidence that treating patients with Substance Use Disorder in the office has been some of the more challenging but some of the most rewarding work I have experienced as a PCP.”

Accompanying the trainings, Center for Population Health has implemented other SUDs-related programs to support Partners clinicians. Part of physicians’ hesitation to obtain waivers is often a lack of training and comfort with how to care for patients with SUDs. Along with medical and psychological challenges, these patients also carry stigma and stereotypes. As Dr. Provenzano has argued, ‘it’s critical for physicians to overcome these barriers.’  To help both clinicians and patients create the best environment for meaningful care, Partners has developed a primary care physician (PCP) mentorship program. In the program, waivered PCPs already prescribing buprenorphine become mentors for new PCPs training for the X-waiver, and are available to support them and make them comfortable with their first few prescriptions. Clinicians can also use the tele-rounds program ECHO (Extension for Community Healthcare Outcomes). The ECHO model is an educational forum where members of the care team can gather virtually to discuss patient cases and share best practices. Here, patient cases can be reviewed by interdisciplinary teams and help determine the best treatment options while also providing ongoing SUDs education for providers.

With further support in and out the exam room, providers are better equipped to support patients with substance use disorders. Clinicians completing the X-waiver trainings are not only making care more accessible for their patients, they are also chipping away the stigma around substance use.

“The greatest barriers that keep people out of treatment have to do with stigma and the ways in which judgmental and outdated views of this illness have permeated our health systems and care models,” says Dr. Wakeman. “Being able to provide effective treatment to your patients with opioid use disorder is not only lifesaving, but also incredibly rewarding.”

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