Treating substance use disorder as a family physician

Patients with substance use disorders may experience stigma that can interfere with treatment options. But when substance use disorders are recognized and treated as a chronic disease, that stigma can be reduced.

Treating patients with substance use disorders in a family medicine setting can be a unique situation because physicians are often treating other members of the patient’s family as well. At first, patients may be reluctant to discuss substance use but once the condition is out in the open, having the family involved can be beneficial.

“I really think it’s an advantage,” said Sarah Fessler, MD, a family physician and president-elect of the Rhode Island Medical Society. “I care for the whole family and it always becomes a family effort to help someone and keep them in sobriety. People definitely have a much better chance of succeeding if they have that family support,” she said.

Working with patients who feel like family

Primary care physicians, especially those in family medicine, know many of their patients very well and have established a long-term relationship. That can be advantageous when a patient begins to show signs of a substance use disorder.

“It’s interesting and tricky,” Dr. Fessler said, “but that’s where it’s helpful to know the person and have a relationship so there’s a certain amount of trust already there. Usually, you get a sense that there’s something else going on when an interaction doesn’t go the way you expect it to in the office.”

“Sometimes I realize that someone has an alcohol problem, for instance, when they end up in the emergency room for an alcohol-induced injury or an overdose,” she said. “In those cases it’s pretty easy to bring it up with the patient.”

“It’s not always that straight forward,” she said. “Sometimes you have to read between the lines a little bit. You know the patient well enough, just like if they were a close family member, you wonder … and by knowing someone in a longitudinal way it’s easier to see that something is going on.”

Acknowledging that the patient’s demeanor has changed by asking, “You don’t seem like yourself today, is something going on?” is a way to begin the conversation, Dr. Fessler said. “You open the door to them, let them know they can ask you for help, and identify yourself as a resource.”

“It becomes a much easier conversation once substance abuse is out in the open,” she said. “And there’s nothing that cements a relationship like reaching out to the patient and offering them help.”

Reducing stigma in the primary care setting

Once the physician and patient have had a conversation about substance use and have determined that it would be best to seek treatment, the primary care setting can be a great place for that treatment to occur. Some patients feel more comfortable when their substance use disorder is treated in the same way as any other medical condition, which can also reduce the stigma.

Dr. Fessler uses medication-assisted treatment (MAT) in her practice and is a waivered buprenorphine prescriber. She has been practicing family medicine in a community health center for 22 years.

“I remember hearing a fellow health center director talk about [MAT] in a very positive way,” she said. “I also remember thinking, ‘I don’t know, it seems like there’re so many barriers to making this work in our office.’”

“But over time, with the opioids crisis, people were moving to even more dangerous forms of opioids,” she said. “I’d seen people overdose and realized that a lot of my existing patients had problems they needed some help with and I decided I should take another look.”

So Dr. Fessler took the training to become a waivered buprenorphine prescriber, and now her practice treats opioid use disorders in house. Her practice is hoping to expand the program to all the primary care physicians in the office because of the positive impact of MAT.

“We are intending to have this as part of our primary care practice,” she said, “taking care of patients’ other needs as well as their substance abuse problems.”

Dr. Fessler and her primary care colleagues are treating many patients with substance use disorders as well. “I view it as another chronic medical problem like high blood pressure and diabetes,” she said. “It’s something we can help them with and I’ve seen some really positive results—people whose lives were spinning out of control really get things under control, get back to work and repair their relationships.”

“It’s not easy for everyone and a lot of people have trouble getting on buprenorphine, staying on it and using it correctly, and they’ll relapse,” Dr. Fessler said. “I took another step back and I thought, well my diabetic patients don’t always stay on their meds either and come to the office and their sugars are really high. But we talk about what worked and what didn’t work, and it seems that that’s human nature. You can keep trying different angles with each patient and eventually it might stick.”

A barrier that has arisen is that some patients don’t show up for the induction of buprenorphine treatment. “Staff is all geared up to help somebody with their induction and they don’t show up, because that’s the nature of substance abuse,” she said. “Sometimes, when it comes down to the wire they aren’t ready.”

“You just keep trying,” Dr. Fessler said. “I leave the door open.”

“If somebody doesn’t show we’ll do a follow-up phone call and I’ll often do that myself,” she said. “They often don’t pick up because they know it’s our office calling, but I’ll leave a message and I’ll say, ‘Sorry we didn’t’ see you, I know this is a hard thing to start, sometimes people just aren’t ready, but if you want to try again the door is always open; or if you’d like to talk about a different kind of treatment I’d be glad to do that too.”

“[Patients] really appreciate being able to come to a primary care provider and not to a substance abuse treatment office,” Dr. Fessler said. “At a primary care provider where they already feel connected and they’re just another patient in the waiting room sitting beside other people who don’t have that same problem, they’re able to shake some of the stigma off. And I think that helps them too.”

“The goal is to normalize it,” she said. “[Substance abuse disorder] is just something that happens, it’s another chronic medical problem and should be treated that way.”

A collaboration to provide more resources

The AMA, RIMS and officials from the Rhode Island Department of Health and the Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals recently announced a partnership to develop and distribute a statewide educational toolbox for healthcare providers to help reverse the state's opioid epidemic. Rhode Island and Alabama are the two states participating in this pilot program with the AMA.

The pilot program will build a toolbox—available online and in print—that incorporates the best information from the AMA, the state medical societies and state health officials. Physicians and other health care professionals will have access to key data, valuable resources and practice specific recommendations they need to enhance their decision-making when caring for patients suffering from chronic or acute pain and opioid use disorders, as well as for patients needing overdose prevention education.

The toolbox will be released in September, and the AMA, the state medical societies and state officials will work together to distribute it throughout Rhode Island. “I hope it makes all this much easier and demystifies a lot of it for physicians who are considering being substance abuse treatment providers,” Dr. Fessler said.

“It’s going to be really helpful to expand our treatment in Rhode Island by just having that support for docs who are on the fence, or are not sure,” she said. “But there’s a long way to go and there’s still way too many overdoses and misconceptions on appropriate treatment of pain. I hope it’s a model for other states.”

Reducing the stigma of substance use disorders and enhancing access to treatment for those who have a disorder is one of the five things physicians can do to prevent opioid abuse, recommended by the AMA Task Force to Reduce Opioid Abuse, which physicians convened to help the nation move closer to the goal of ending the opioid epidemic.