America, Love It or Heal It

A blog about health, health care, and health care reform

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Addictions in the primary care office

As with any disease, prevalence of this narcotics abuse is region-specific; an hour north of the office where I practice, Rio Arriba County in New Mexico is home to one of the highest opioid overdose rates in America – up to five times higher than the national average.  Our patients routinely lose family to addictions; our clinic has been home to a near-fatal overdose within the walls of the facility.

Addictions treatment has always orbited the periphery of mainstream medicine, and the recovery community has traditionally been averse to medical intervention for what was historically considered a condition of weak will, most amenable to talk therapy and group support.  With the advent of supported sobriety medications like buprenorphine for opioid dependence and naltrexone for alcohol cravings, addictions treatment has shifted  sharply toward a medicalized model.  But with an estimated 23 million Americans needing help with addictions (2 million of those dependent on opioids alone) and a few thousand addiction specialists across a number of specialties (the exact number is difficult to estimate, as the American Board of Medical Specialties does not recognize an addictions medicine specialty outside of psychiatry), the numbers simply do not add up: too many patients, too few specialists.  The result is that patients are simply not offered straightforward, life-saving medicine.  An appropriate analogy is a situation in which all diabetics are denied treatment unless they locate themselves an amenable endocrinologist.

The only specialty with a front-lines army legion enough to provide for this population is primary care.  But primary care has been remiss in stepping up to its responsibility for this routine condition.  Some offices feel they lack resources to address high-needs populations; some offices do not wish to attract such patients, politely ignoring that few clinics do not already count such patients among their loyal rosters.  Ironically, addictions treatment is not a difficult area of medicine to learn anew; still in its infancy, there are only a handful of drugs in limited regimens to effect change in addicted patients – making this field far less complex than, say, metabolic syndrome. An addicted patient should be able to walk into any primary care clinic in America and receive standard-of-care treatment on site – just as they would for hypertension or diabetes.

As long as addictions are marked as a condition to avoid and disdain, critical masses of providers needed to battle back the tide of narcotics abuse will not emerge.  Primary care must become the locus of outpatient treatment, with inpatient and/or specialty treatment reserved for the most ill or incorrigible cases.  Primary care training centers must teach evidence-based use of supported sobriety medications; states can support such resources by offering tax breaks to practices that provide rare services, as is currently proposed in New Mexico.

Addicts in recovery are a uniquely rewarding population – I can think of no other disease whose sufferers beg for their place among woefully inadequate programs, and profusely thank me for helping them wrest their lives back from the abyss of a difficult existence and early mortality.  These patients already haunt the halls of just about every clinic in the nation, quietly seeking help for a dependence that they may or may not admit to their physician.  Whether in high-prevalence crisis zones like northern New Mexico or in areas of average abuse, primary care owes it to our patients and our profession to face down this epidemic, to meet the challenges of our time.

Also posted at KevinMD.com