You arrive at work to learn one of your patients, a young woman, has texted her mother threatening to commit suicide by overdosing on heroin. Meanwhile, another patient is waiting to receive a Pap smear. That’s a glimpse into a recent day for Marla Kushner, DO, whose Chicago practice melds primary care and addiction medicine. “There’s really no predictability, but that keeps it exciting and interesting,” says Dr. Kushner, who notes that she was able to reach and calm the suicidal patient.
The majority of Dr. Kushner’s patients with addiction are young adults struggling with opiate dependency. Opiate addiction is an increasingly common problem in the Chicago area, she explains. Chicago’s suburban counties saw a spike in heroin-related deaths in 2012, with deaths in some counties increasing two and threefold, the National Institute on Drug Abuse reports. Deaths from heroin use are increasing across the country, too, according to the Centers for Disease Control and Prevention.
Such concerning statistics may evoke negative stereotypes of addicted patients. But Dr. Kushner is quick to point out that addiction is a brain disease and shouldn’t be cause for stigmatization. “Most of the people I treat with this disease are really intelligent, bright, otherwise successful people who, when they’re under the influence of these different drugs or alcohol, don’t make the smartest decisions and end up in a lot of trouble,” she explains. Practicing addiction medicine within a primary care practice, Dr. Kushner says, means addiction patients can come to her for any medical needs. They will know the medication and treatment they receive will be safe for their recovery.
In bringing addiction medicine under the umbrella of primary care, Dr. Kushner is part of a growing trend. Medications such as buprenorphine, which reduces cravings and withdrawal symptoms for patients addicted to opioids, can be prescribed in an office setting once physicians complete training and obtain a waiver. The waiver allows doctors to provide medication-assisted opioid addiction treatment using specific FDA-approved Schedule III, IV or V narcotic medications. That’s a big departure from the regulations that govern methadone treatment, which is available only in accredited treatment clinics. Policy changes are driving the trend too; under the Affordable Care Act, addiction treatment is now an essential health benefit.
Because patients with addiction may have a constellation of health issues, including mood disorders or hepatitis or HIV, they can benefit from receiving care from a primary care physician who’s deeply familiar with their story. “I think that the primary care setting is the ideal place to treat the disease of addiction as long as the treating physician is familiar with how to treat these patients,” Dr. Kushner says. “Primary care physicians know their patients very well and generally view them more holistically. This can make all the difference with patients who are dealing with addiction.”
Training the next generation
Despite the changing landscape of addiction medicine, many medical students don’t get extensive training in the field, according to the American Osteopathic Academy of Addiction Medicine (AOAAM). To help bridge the gap, Dr. Kushner, who serves on the AOAAM’s board of trustees, lectures third-year students at the Midwestern University/Chicago College of Osteopathic Medicine in Downers Grove, Illinois. Her practice also offers a family practice rotation and slots for pediatric and internal medicine residents. “I think of everything I do, the addiction stuff is the most fascinating for them,” Dr. Kushner says. “That’s not something they can see everywhere.”
Building patients’ trust
One way Dr. Kushner has connected with her patients is by starting a therapy group for patients who take Suboxone as part of treatment for opiate addiction. The medication uses a combination of buprenorphine and naloxone to reduce cravings and withdrawal symptoms. Because it’s an alternative to quitting “cold turkey,” patients taking Suboxone may not feel welcome in traditional 12-step programs. Dr. Kushner’s therapy group allows them to talk about their recovery with an understanding cohort.
“It’s been an incredible way to learn more about my patients and their struggles and successes,” she says.
Anthony Dekker, DO, met Dr. Kushner nearly 30 years ago in Chicago when she started her fellowship in adolescent and young adult medicine. At that time, Dr. Kushner stood out as an enthusiastic learner who wanted to tackle the difficult problems facing young adults and high-risk populations, says Dr. Dekker, who is now a primary care and telemedicine physician in Prescott, Arizona. Over the years, Dr. Kushner has served as an energetic advocate for teens, young adults and their families, Dr. Dekker says.
“Marla has exemplified the concept of treating people with respect, being accessible for their care and treating the whole person with excellence,” he says.
Treating patients with addiction, Dr. Kushner emphasizes, is similar to helping them manage any other chronic condition. “You’re not going to turn away a diabetic because they ate a piece of chocolate cake, right?” she says. “You’re going to work with them and help them manage their diabetes. It’s the same way with addiction.” Once patients recognize that they have a problem and seek treatment, Dr. Kushner says, they can start making wise choices and get their lives back on track.