Expanding primary care buprenorphine treatment could curb opioid overdose crisis

Expanding the availability of medication treatment for opioid use disorder in primary care settings would be a major step toward reducing overdose deaths, write two physicians specializing in addiction medicine and health care delivery in the July 5 issue of New England Journal of Medicine. In their Perspectives article entitled "Primary Care and the Opioid-Overdose Crisis – Buprenorphine Myths and Realities," Sarah Wakeman, MD, medical director of the Massachusetts General Hospital Substance Use Disorders Initiative and Michael Barnett, MD, of the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, describe current barriers to expanded delivery of buprenorphine treatment and outline possible solutions.

"One of the tragic ironies is that with well-established medical treatment, opioid use disorder can have an excellent prognosis," they write, noting that almost 80 percent of Americans with opioid use disorder are unable to receive treatment and that the growth in distribution of buprenorphine – one of three FDA-approved medications for the treatment of opioid use disorder – has been slowing rather than increasing in recent years. "To have any hope of stemming the overdose tide, we have to make it easier to obtain buprenorphine than to get heroin and fentanyl."

The authors describe 5 persistent but inaccurate myths that they believe prevent buprenorphine from being more widely adopted:

  • That is more dangerous that other common health care interventions,
  • That buprenorphine treatment is just replacing one addition for another,
  • That abstinence-based treatment – short-term detoxification and rehabilitation – is more effective than medication-based treatment,
  • That providing buprenorphine treatment is particularly onerous and time consuming for primary care physicians (PCPs),
  • That physicians should just reduce opioid prescriptions to address the overdose epidemic

Most outpatient buprenorphine treatment is already provided by PCPs, and expanding the availability of office-based buprenorphine treatment, as several other countries have done, presents a realistic solution to addressing the overdose crisis, the authors note. They write, "We are in the midst of a historic public health crisis that demands action from every physician. Without dramatic intervention, life expectancy in the United States will continue to decline. Mobilizing the PCP workforce to offer office-based buprenorphine treatment is a plausible, practical, and scalable intervention that could be implemented immediately."

Wakeman is an assistant professor of Medicine at Harvard Medical School (HMS) and a physician at Massachusetts General Hospital; Barnett is an assistant professor of Health Policy and Management at the Harvard Chan School, an instructor in Medicine at HMS and a Brigham and Women's Hospital physician. Their article is one of three addressing improvements in medication treatment for opioid use disorder in the same NEJM issue.

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Harvard T.H. Chan School of Public Health brings together dedicated experts from many disciplines to educate new generations of global health leaders and produce powerful ideas that improve the lives and health of people everywhere. As a community of leading scientists, educators, and students, we work together to take innovative ideas from the laboratory to people's lives–not only making scientific breakthroughs, but also working to change individual behaviors, public policies, and health care practices. Each year, more than 400 faculty members at Harvard Chan School teach 1,000-plus full-time students from around the world and train thousands more through online and executive education courses. Founded in 1913 as the Harvard-MIT School of Health Officers, the School is recognized as America's oldest professional training program in public health.

Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH Research Institute conducts the largest hospital-based research program in the nation, with an annual research budget of more than $900 million and major research centers in HIV/AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, genomic medicine, medical imaging, neurodegenerative disorders, regenerative medicine, reproductive biology, systems biology, photomedicine and transplantation biology. The MGH topped the 2015 Nature Index list of health care organizations publishing in leading scientific journals and earned the prestigious 2015 Foster G. McGaw Prize for Excellence in Community Service. In August 2017 the MGH was once again named to the Honor Roll in the U.S. News & World Report list of "America's Best Hospitals."

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       http://dx.doi.org/10.1056/NEJMp1802741 
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