Our patient sat in the waiting chair, nervous and clammy. His golf shirt began to stain with sweat as he fidgeted and played with his wedding ring. Heart pounding, nerves racing, his stomach twisted in knots.
He wasn’t in withdrawal. He was five years clean and planning to be out of town for more than four weeks. He was here for his Suboxone refill and he needed an extension beyond the 30-day mandate for narcotics.
For years, this man came religiously every month for treatment, with no missed appointments and clean urine tests. During his last work trip, he had to produce his airline tickets and hotel reservation before the pharmacy would take a second look at his refill.
The years of shooting up, stealing, and addiction were long behind him, but stigma never left. He had the initiative to start treatment. He was successful in a new job, with a stable livelihood. Yet he felt almost criminal trying to get the medication that helped him stay sober.
Feeling criminal about opioid treatment is a feeling shared by physicians.
The biggest problem to battling opioid addiction is that the treatments themselves involve narcotics. Understandably, most physicians decline to treat opioid addiction based solely on this fact.
Additionally, the debate of “choice” versus “disease” is unfortunately still prevalent among health care
Opioid dependence is a disease. To successfully treat this epidemic, we must manage it like any other type of disease. Treating diabetes does not involve temporary insulin. The condition is always there and some type of treatment will always help.
People who have been or are currently addicted to opioids will always be addicts.
Office-based opioid agonist treatment
Depending on the severity of the disease, opioid treatment can range from lifestyle modification to inpatient rehab. The middle ground is office-based opioid agonist treatment (OBOT).
OBOT therapy is a reasonable alternative to treatment in a methadone clinic. Instead of waiting outside of a clinic each day, patients receive a once-a-month prescription of buprenorphine (Suboxone) from a physician.
Coupled with naloxone, the three forms of Suboxone treatment result in sudden withdrawal when injected or snorted. If taken as prescribed, the naloxone effects are negated and patients feel relief without concomitant symptoms. This safeguard against potential abuse also makes it easier for a primary care physician to manage.
OBOT therapy is relatively new and some practitioners are unaware of this treatment modality. Additionally, federal guidelines require an eight-hour course for primary care physicians to be certified in Suboxone treatment. The process is tedious. In the first year after certification, the physician can see a maximum of 30 patients for Suboxone treatment.
Why would any physician want to go through all of these steps? The answer is simple. The opioid epidemic has come to the point that physicians need to stand up and say, “I am here to help.”
Who are we helping? I’ve seen middle-aged mothers in for treatment, embarrassed about their pill habits. Their families, spouses, and children are unaware of their addiction.
I see many hard-working men who struggled for decades against addiction because of one back injury. I’ve seen an elderly woman in tears because she got hooked on Percocet. “My doctor,” she said, “She kept pushing the prescription up. And I’m hooked. I’m a grandmother and I’m a drug addict. This was never supposed to be me.”
We are no longer treating a small minority of the population. We are treating our neighbors, our children, our elderly and our friends. Office-based opioid agonist treatment is an ideal place for many primary care physicians to start.