Overdose Epidemic

Understanding addiction and treating patients with substance use disorders with Bobby Mukkamala, MD


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National Addiction Treatment Week kicks off today with Bobby Mukkamala, MD, chair of the AMA Substance Use and Pain Care Task Force, discussing the stigma of addiction, common barriers to substance abuse treatment and physician advocacy efforts in the fight against the overdose epidemic in the U.S. Dr. Mukkamala also shares advice for doctors and practitioners on treating opioid use disorder and patients struggling with addiction. AMA Chief Experience Officer Todd Unger hosts.


  • Bobby Mukkamala, MD, chair, AMA Substance Use and Pain Care Task Force

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Unger: Hello and welcome to the AMA Update video and podcast. To kick off National Addiction Treatment Week, we're talking about how we can reduce the stigma of addiction and the crucial role that physicians play in addiction treatment and recovery. Here with me to discuss that is Dr. Bobby Mukkamala, chair of the AMA Substance Use and Pain Care Task Force in Flint, Michigan. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Mukkamala, it's a pleasure to have you back.

Dr. Mukkamala: Thanks, Todd. It's good to be back. Thanks for having me.

Unger: Well, today is the start of National Addiction Treatment Week. Dr. Mukkamala, let's just start by talking about the purpose of this week.

Dr. Mukkamala: Yeah, so this week was organized by the American Society of Addiction Medicine, and the AMA is a co-sponsor, as we have been in past years. And it's a time to reflect on the fact that there are more than 100,000 Americans dying each year of a drug-related overdose and then more than 100,000 people each year dying of causes related to alcohol use, and these are preventable deaths.

And while this is just one week, it's important, though, to shine a bright light on the fact that we need to step up our efforts if we're going to change those numbers. So it begins today on October 16 and runs through the 22nd. And it's designed to serve as a powerful reminder that addiction is a treatable chronic disease and not a moral failing. And everyone can play an impactful role in saving lives and communities affected by addiction.

The medical community in particular is on the front lines in the fight to prevent and treat addiction. Physicians' expertise and compassion are going to be pivotal in spreading awareness that recovery is possible. And so this week is also an important reminder that we all got to work together to help individuals when they're ready to start treatment and that we help them find evidence-based care, maintain that treatment, and support a long-term recovery for them.

Unger: Dr. Mukkamala, I want to talk a little bit more about the issue of stigma. You mentioned in your last comment there that a lot of people think that addiction is a personal or moral failure or weakness. And that can even be true in the medical community. How does this affect care and treatment?

Dr. Mukkamala: Yeah, it's certainly a barrier to care. And the medical community has got to be a leader in removing stigma. Fear of being judged or shamed itself can keep people from seeking the care or treatment in the first place, care that they need. And there's many reasons why people might start using a substance, whether that's alcohol, whether that's diverted prescription medication, whether that's illicit substances.

Judging our patients doesn't help their disease, and it shouldn't be a part of any medical practice. So consider the patient that might show up in our exam room with alcohol on his or her breath. What do we do in that situation? Or if we learn that a patient is misusing prescription medications, what do we do? Or if we looked at a patient's medical history and saw that there was a prescription for medication to treat a substance use disorder, what do we do?

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I know it would make many of us uncomfortable, and I understand that. Unless we actively are treating somebody with a substance use disorder, we probably aren't going to have much experience with screening for substance use disorders, let alone treatment or referral of that patient. So it makes us uncomfortable, and we need to accept that so that then we can take the next step and start understanding that patients with substance use disorders have a chronic disease.

So when I check the PDMP and see that a patient on my schedule for a nose surgery, for example, which are kind of painful, is on methadone treatment, I have a choice to make at that moment. And that's that discomfort of, OK, what do I do with this patient? And we're encouraging people to make the right choice when they're treating these patients.

And so the AMA and the nation's medical societies continue to emphasize the need to treat patients with addiction with care and compassion. And we've made progress, but we know that there's a whole lot more work to be done and reducing the stigma is going to save lives.

Unger: Now, unfortunately, stigma isn't the only barrier. You mentioned that there were other barriers to care. Talk to us a little bit more about what those barriers look like and how they make it difficult for people to get the treatment that they need.

Dr. Mukkamala: Yeah, you're absolutely right in that the underlying medical condition is hard enough. But on top of that, to have some barriers—and I'll just highlight three of them—health insurance companies that deny or delay care, pharmacy chains that don't stock lifesaving medications, and policies that punish pregnant people for having a substance use disorder.

So one of the biggest health insurance company barriers that physicians are all going to fall into is prior authorization. Health plans make physicians spend hours on paperwork and phone calls to justify proven, evidence-based treatment for opioid use disorder. If a patient with a substance use disorder is forced to wait for care, that patient is going to suffer intense and painful withdrawal symptoms. They might return to using illicit substances while they're dealing with those symptoms and overdose and die, all because of these insurance company hurdles.

Second, for opioid use disorder, buprenorphine is generally considered the gold standard of treatment. But more than 40% of pharmacies don't stock this medication. Stigma of not wanting "those patients" in a pharmacy likely plays a huge factor. And there are many states that have laws essentially criminalizing addiction when a person is pregnant.

And so what happens is that, rather than doing everything possible to get a pregnant person into treatment so her pregnancy can be safely and effectively managed, state laws subject those pregnant people to intrusive investigations that actually scare people away from seeking care. So rather than improve care, these punitive laws make it worse for pregnant people, the fetus, the newborn, their family members. So the AMA really wants to encourage pregnant people who use substances to seek care without fear. And that's going to take changing state laws in many cases.

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Unger: Now, Dr. Mukkamala, you mentioned prior authorization there. I want to talk in this next part here about what the AMA is doing to fight issues just like that.

Dr. Mukkamala: Yeah so our AMA advocacy team is actively working to overcome many of these barriers and has been for a long time. So on the barriers I mentioned above, for example, the AMA is working closely with departments of insurance and state medical societies to remove prior authorization for medications for opioid use disorder.

We're fighting hard to increase penalties against insurance companies who violate the law by having an inadequate network of physicians to treat addiction and mental illness. And the AMA's fighting to increase access to evidence-based care by urging the DEA to maintain helpful telehealth rules that allow treatment via audio-only or audio/visual patient visits. The AMA is urging departments of insurance to investigate and hold accountable these health insurance companies that illegally deny or delay care for patients with substance use disorders.

We've got model state legislations to revise state laws that punish pregnant people with a substance use disorder, and hopefully start to remove the fear and stigma they feel. So we're urging state Medicaid agencies to remove, for example, dosing restrictions for buprenorphine, as part of those innovative strategies to address this rising fentanyl use. And when we see these newer illicit fentanyls, the dosing is higher for buprenorphine. So these older rules that were conceived when illicit fentanyl at the concentration that it's there now wasn't around need to be changed.

And another important treatment that we're fighting for is methadone, another gold-standard medical treatment for opioid use disorder that's safe and effective for patients when indicated and dispensed and taken properly. So as part of those efforts, we're backing the Modernizing Opioid Treatment Access Act, which would allow board-certified addiction medicine or addiction psychiatrist physicians to prescribe methadone for opioid use disorder in the community rather than requiring all those patients who benefit from methadone to make daily trips back to an opioid treatment program. And I could detail many more AMA advocacy efforts, but the bottom line is that we've already succeeded on multiple fronts, but there's a lot of work still to be done.

Unger: And all that work you described there, much of it, including the work on prior authorization—all part of the AMA's Recovery Plan for America's Physicians. I'd urge you all to take a look at that on the AMA site at ama-assn.org/recovery.

Dr. Mukkamala, let's kind of end where we began with discussion around the National Addiction Treatment Week. In closing, what do you hope that physicians specifically hear this week?

Dr. Mukkamala: You know, what we really need is for all physicians to engage on this issue in our country. It's not that all physicians are going to treat addiction, but we can all be part of the solution in some way. So given this, we're urging physicians to learn more about addiction and evidence-based approaches to care. This is going to help overcome stigma and create a more compassionate health care system.

So just as we talk to our patients about other stigmatizing medical conditions, whether that's obesity or depression or anxiety, we can do better to normalize the fact that having pain or having a substance use disorder deserves our care and compassion in the same way. So physicians can engage this week, access these available resources, and learn more about how to help patients with substance use disorders by visiting, for example, treataddictionsavelives.org. There, they're going to find resources to spread the message on social channels using #TreatmentWeek. Awareness is a potent tool for change.

Unger: And if a physician wants to get involved and follow the AMA's efforts beyond this week, what's your recommendation there?

Dr. Mukkamala: Yeah, I mean, I think that's wonderful, and physicians can always get involved and track the AMA's efforts at end-overdose-epidemic.org. And so just as we talked about last time, physicians' advocacy doesn't have to be on Capitol Hill. It can be in your state and specialty societies. It can also be in your exam rooms. It should be in your exam rooms through conversations with patients about safe storage, disposal of opioids and other medications and the risk of overdose, and how to access and use naloxone.

Addiction is treatable, but it's not going to get better until patients received evidence-based care. And this means we all have got to work together—physicians, policymakers, organized medicine, law enforcement, communities. So National Addiction Treatment Week is a great initiative to raise the awareness about addiction, but we need to be having these conversations all year round. It's got to go beyond just designated days and weeks to truly put an end to this epidemic.

And if any of the policies that we mentioned here sound interesting to folks listening, and you want to get involved, then contact your state medical society or your state specialty today and tell them you want to see action. And tell them that the AMA is ready and willing to help every state make these changes that are necessary.

Unger: That's a great way to close. Again, find out more information at end-overdose-epidemic.org. Dr. Mukkamala, thanks so much for being here today and for all the work that you and the task force continue to do to address this epidemic. We'll be back soon with another episode soon. You can find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today and please take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.