How to refer a patient with opioid-use disorder to a specialist

Andis Robeznieks , Senior News Writer

The numbers illustrate the enormity of the public health problem: About 48,000 people died from an opioid-related overdose between January 2017 and January 2018, with the majority of those deaths linked to heroin and illicit fentanyl.

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Stepping up to meet this challenge are the more than 54,000 physicians and other health care professionals who are certified to provide in-office buprenorphine treatment for opioid-use disorder (OUD), up from less than 38,000 last year.

Physicians looking for guidance on providing more specialized treatment can visit the AMA Opioid Task Force webpage to find resources such as a link to the Substance Abuse and Mental Health Services Administration (SAMHSA) buprenorphine treatment practitioner locator to find colleagues who can help.

Kelly J. Clark, MD, is president of the American Society of Addiction Medicine and founder of Addiction Crisis Solutions. She said there are three things physicians can do to get help patients get the opioid specialty treatment they need:

  • Use online tools to find a specialist.
  • Build relationships with specialists in their area.
  • Learn how to provide specialized treatment themselves.

Before going down one of those paths, however, Dr. Clark said physicians should complete a traditional assessment of the patient, just as they would do with any other condition.

The goal is to determine the acuity of their patient’s problem.

It could be determined that the patient’s apparent OUD may be a symptom of depression or that there is a “problematic dosage” with their pain medication that may need tapering, Dr. Clark said.

If the patient’s needs are determined to beyond what the physician is comfortable providing, then he or she should start looking for a specialist using these short- to long-term strategies.

Use online tools. The SAMHSA locator can be helpful. Also, Dr. Clark noted that the ASAM website has a list of members that is searchable by name, city, state and ZIP code and can be filtered by board certification in addiction medicine, preventive medicine, psychiatry or neurology. There is also a link to a database that specifically searches for those who treat OUD with naltrexone.

While emphasizing that treatment should involve more than writing a prescription, Dr. Clark said patients with OUD and their families should seek care from clinicians who discuss the risks, benefits and alternatives of all FDA-approved medications for the treatment of OUD, and use them in their treatment program.

Use your connections. Physicians should make the most of relationships made through state and county medical societies to locate physicians in the community who specialize in treating OUD.

For example, Dr. Clark remains active with the ASAM chapter in her home state of Kentucky and works with the Kentucky Medical Association and county physician organizations to provide speakers for local meetings. Through these events, primary care physicians or general psychiatrists can build a network of trusted specialists they feel comfortable referring their patients to.

Become a specialist yourself. Noting that “we lack the infrastructure to deal with this disease,” Dr. Clark invited physicians to take the eight-hour course necessary to get certified to prescribe buprenorphine, and then go further with a 40-hour ASAM course on the fundamentals of addiction medicine.

“Primary care physicians and doctors of all types can enter the fight against the opioid epidemic,” Dr. Clark said.

The Providers Clinical Support System (PCSS) is a SAMHSA-funded coalition of major health care organizations that includes the AMA. PCSS is led by the American Academy of Addiction Psychiatry (AAAP) and its mission is to train physicians to deliver evidence-based treatment for OUD.

As part of this process, PCSS funds training programs offered by organizations certified under the U.S. Drug Addiction Treatment Act of 2000—such as AAAP and ASAM—for physicians seeking a waiver to provide office-based buprenorphine treatment for OUD.

In addition to training, Dr. Clark said PCSS connects physicians to local mentors who can answer questions not found online.

Dr. Clark notes that her own psychiatry training did not include delivering medication-assisted treatment, but she had an “aha moment” while shadowing a colleague at a methadone clinic and she encourages other interested physicians to do the same thing.

“Patient after patient described the experience as saving their lives,” Dr. Clark said. “No one tells the story of getting into remission better than the patients themselves.”