Opioid Dependence: The case for family physicians

As the national opioid crisis takes center stage I want to make a case for the primacy of the family physician in managing and treating this problem.

I am a family physician and have been treating patients with opioid dependence and addiction for 12 years.  These patients comprise about half of my practice.  The other half is representative of a typical primary care practice.  I have patients who have been treated at methadone clinics, dedicated buprenorphine clinics, and pain clinics.  My patients have participated in hospital-based detox programs as well as outpatient and inpatient rehabilitation programs.  Most of my patients have had professional counseling of one form or another.

A lot of money is being thrown at this problem and there is no shortage of businesses looking to be on the receiving end.  Families and individuals are spending thousands of dollars in the hope that something will work.  Unfortunately, some of these facilities promote expensive, unproven treatments.  Some require frequent, regular visits for counseling that have not been shown to have a long-term benefit over less frequent visits or even no counseling at all.  I have seen many patients released after 30-day inpatient stays only to relapse within a week of discharge.  Treatment centers offering comfortable, home-like environments are springing up like fast food restaurants.  The packaging is fancy but is the product any more effective?  I see dedicated pain clinics and “suboxone” treatment clinics maintaining patients on high doses of buprenorphine never having engaged the patient in a serious discussion of weaning.  Are these clinics really interested in helping patients overcome their dependency?  I  wonder.

While I support research into the most effective way to treat opioid dependence and addiction, I remain unconvinced that any of the aforementioned treatment options is any more effective than what I am able to accomplish in my own practice.  In fact, given that my patients pay a fraction of what they would pay in some of the more “comprehensive” treatment facilities, I can make a good argument that what I do in my clinic is actually far more cost-effective…even if I am unable to claim better outcomes.

You cannot fast track the treatment of opioid dependence.  Additionally, it is not a “one size fits all” solution.  I am not an expert in the neurophysiology or psychology of opioid addiction but I am a keen and experienced observer.  I don’t believe you can treat this problem in 30 days or with a prescribed amount of counseling.  I am convinced that most people who are able to conquer this problem will go through a process spanning years.  This is a complex problem to be sure and one which I believe the family physician is uniquely suited to address.

Let me explain.

Treatment of Opioid dependence and abuse does not occur in a vacuum.  Many carry a dual diagnosis referring to coexisting mental illness.  Anxiety and depression are both very common.  These patients also present with all of the same problems and concerns of the general population.   Additionally, there are many comorbid problems that occur.   For example, sleep problems such as insomnia and sleep apnea are extremely common.  Males commonly develop symptoms of low testosterone.  A high percentage of these patients are treated with stimulants for ADHD.  I have encountered issues with hypertension and tachycardia.  Something that makes my services especially cost-effective is that I am often addressing these issues in addition to managing their opioid treatment as well as any other problems they may present with.

Over time a deep level of trust develops between provider and patient.  This trust is key to effectively treating this perplexing problem because that trust is what allows the patient to open up to in a way that enables the provider to appreciate the physical, mental, emotional, social and spiritual factors that affect good health.  Without this understanding, it is not possible to determine the best approach to a particular patient.

Counselors, psychologists, pain specialists and dedicated treatment facilities do not share this comprehensive, one-stop capability.  I am not suggesting that other healthcare professionals do not contribute in a meaningful way.  What I am suggesting is that in an era where healthcare financing is more challenging than ever, the family physician with an interest in opioid dependence is a great bargain and perhaps the most cost-effective option in the treatment of opioid dependence.

Layne Kamalu MD

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