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September 9, 2019

Why even doctors with opioid use disorder seldom get 'the gold standard' of care

Daily Briefing

    While medication-assisted treatment (MAT) is considered "the gold standard" for managing opioid misuse disorder, many state programs for health care professionals seeking to recover from opioid use deny providers access to these medications, Selena Simmons-Duffin reports for NPR's "Shots."

    Substance use disorder: How to keep your patients and colleagues safe

    The story of a doctor addicted to Vicodin

    Peter Grinspoon is a licensed primary care physician who teaches at Harvard Medical School. But in medical school Grinspoon became addicted to Vicodin, and as a primary care doctor, he wrote himself fraudulent prescriptions for the drug until 2005, when police and the Drug Enforcement Administration showed up at his door.

    Grinspoon was charged with three felony counts of fraudulently obtaining a controlled substance and was referred to his state's physician health program (PHP), Duffin reports. PHPs work with state licensing boards to treat and monitor health care professionals who develop substance use disorders. To get their licenses back, providers have to follow the PHP's plan. For Grinspoon, who was facing a criminal record, that meant 90 days at an inpatient facility.

    However, Grinspoon said the program didn't offer what many providers today believe to be standard care for opioid use disorder: counseling coupled with buprenorphine or methadone, forms of MAT.

    "I was just sitting there listening to people recite the Lord's Prayer and hold hands," Grinspoon said of the program. "They took me cold turkey off all my medications. It was completely insane."

    After several rehabs that Grinspoon characterized as awful, Duffin reports, he's stayed sober and today has his medical license.

    Still, he's critical of PHPs that deny health care professionals MAT. "Why on earth would you deny physicians who are under so much stress … and … have a higher addiction rate" this treatment, Grinspoon asked.

    PHPs seldom promote MAT 

    While Grinspoon went through a PHP more than a decade ago, his experience is still common, Duffin reports.

    According to Harvard's Sarah Wakeman, few PHPs promote MAT. "The sort of general standard of care is to send people to abstinence-based residential treatment programs that don't offer medication treatment," Wakeman said. In a recent editorial in the New England Journal of Medicine, Wakeman and her co-authors described PHPs as follows: "The programs 'promote early detection, assessment, evaluation, and referral to abstinence-oriented (usually) residential treatment for 60 to 90 days,' followed by random urine toxicology screening for roughly five years."

    In an interview with NPR, Wakeman said, "I think the underlying issue is stigma and the sort of misunderstanding of the role of medication and this idea that a non-medication-based approach is somehow better than someone taking the medication to control their illness."

    Could MAT increase risk of error?

    Meanwhile, Christopher Bundy, a physician who runs Washington state's PHP and is president-elect of the Federation of State Physician Health Programs, said it's important to note that there's no ban on MAT for health care providers. "There are doctors [and nurses] across the country who are being monitored on buprenorphine."

    However, he acknowledged those cases aren't the norm.

    One reason for not adopting MAT for providers is concerns that it could impair cognition, Bundy said.

    "We only need one bad outcome involving a physician with substance use disorder who's back to work, then immediately the PHP is under the microscope." He disputed the notion that stigma or ideology are the reasons why MAT isn't often used for health care professionals.

    Duffin reports that Bundy does not know of a case in which MAT led to a bad patient outcome.

    Similarly, Wakeman and her co-authors in their editorial argue that there isn't clear evidence to show that MAT increases the risk of error. In their editorial, they write, "Systematically denying clinicians access to effective therapy is bad medicine, bad policy, and discriminatory" (Simmons-Duffin, "Shots," NPR, 9/6; Beletsky et al., New England Journal of Medicine, 8/29; NPR, 9/5).

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