Opioid Use Disorder Treatment is Primary Care
I’ve been treating opioid addiction for as long as I’ve been a physician. My residency clinic was one of the few places in our rural community where folks could go for medication-assisted treatment, or MAT. We were a regular family medicine clinic, but about half of our patients originally found us cause they were looking for help with their opioid use. It was a pretty cool way to learn primary care. Now that I have my own practice, it’s important to me to offer this type of treatment to my community here in Milwaukee.
What is MAT?
Let’s start with what MAT isn’t. It’s not a cure for addiction, because that doesn’t exist. MAT lets us manage addiction as a chronic disease. And just like with managing diabetes or heart disease, taking your meds is only the beginning. Getting better takes work. And that means there is no medication that’s going to motivate someone to get clean who isn’t ready yet. It’s also not something that’s going to work for everyone, cause no medications do. I’d love to prescribe a unicorn that farts rainbows and makes treatment quick and easy and is universally effective, but it’s just not in my toolkit yet. I’ll let you know when that becomes available.
The goals of MAT are to keep people alive by preventing overdoses, and to allow them to have a life that doesn’t revolve around drugs. If you’re in the depths, that last part might sound as unrealistic as the farting unicorn, but I promise it’s not. Medications can make a big difference to someone’s chances of success at getting clean, and even more importantly, of staying safe as they begin recovery. But as of 2020 here in Milwaukee county, only about 20% of people getting drug treatment were getting MAT. So I feel pretty strongly that primary care doctors need to be able to offer this.
Another way to think of MAT is as a tool to handle physical symptoms of addiction so that you can focus on the psychological work. Just about everyone needs counseling, ideally addiction-specific counseling (yes you’re going to have to work through your shit, yes you’re going to have to do it clean and sober, and yes it’s gonna be hard that’s why you do it with a professional). Intensive outpatient therapy can be a good option, and disrupts patients’ lives less than going to rehab. Many people benefit from traditional 12-step programs like Narcotics Anonymous or variations on that idea like Smart Recovery. Peer support groups and sober living residences can help. Exercise, healthy sleep, and nutritious eating are all important. Addiction is rarely the only thing going on; the issues that make a person vulnerable to addiction like depression, anxiety, trauma, or chronic pain need to be addressed as well. Wisconsin’s addiction recovery helpline is a good place to find resources.
On Overview of Treatments for Opioid Use Disorder
Ever heard this joke? Why do they keep telling us “Say no to drugs?” If you’re talking to your drugs, it’s probably too late to say no.
It’s the 21st century and we know better than to think recovery is just a matter of willpower. Addiction is incredibly complex and there’s a lot we still don’t understand. But there are treatments that can increase your chances of successfully quitting opioids.
DETOX
In my opinion detox is an outdated approach, but unfortunately it’s the only kind of help many people have access to. In detox the patient withdraws from opioids in a hospital setting with supervision and treatments like IV fluids to prevent dehydration or short term medications to help with some of the withdrawal symptoms like vomiting and diarrhea. After a few days the patient is discharged, and depending on where they detox, they may or may not have good support, like counseling, afterwards. The success rates for detox are not awesome, and the risk of relapse afterward is high. But that’s not the worst part. The worst part is that after going through detox, the people who relapse are especially vulnerable to overdose and death, because their body is no longer used to the drugs. That makes detox the most dangerous way to get clean.
NALTREXONE
Next comes naltrexone. That is an opioid blocker, available as a pill or as a monthly injection. The idea is as simple as it sounds—while naltrexone is in someone’s system, they can’t get high or overdose from opioids. It helps some with cravings as well. It’s not the most effective type of medication, and it can only be used after someone has been through detox, but it rarely causes serious side effects and it does improve patient’s chances of success compared to no medication at all. For some people it’s the best tool available and I do prescribe it for a small number of patients. Unfortunately, as of this writing, we have a national shortage of naltrexone pills and I haven’t been able to prescribe that form for months.
METHADONE
Then there’s Methadone, which the most effective kind of medication-assisted treatment. This approach doesn’t try to reverse the patient’s dependence on opioids, but rather to substitute a safer alternative. Methadone works on the body much the same way that opioids like heroin, fentanyl, oxycodone do, except that it doesn’t produce euphoria (the high). Methadone is also safer and less prone to side effects, and of course, you take it in a medically supervised setting with careful monitoring.
For many people methadone is a great, life-saving treatment—so whatever mean jokes you’ve been making about methadone clinics, it’s time to get fresh material. The drawback to methadone is that it’s a complicated medication that requires supervision from a doctor with a special license, so it’s not something a primary care doctor like me can prescribe in a regular office. In the beginning patients typically have to go to a special center every day to take their medications, which can be hard if you have transportation barriers or an unpredictable work schedule. Some patients also experience strong side effects that they’re not able or willing to tolerate for the long term.
BUPRENORPHINE
Now we come to the medication I use most often: buprenorphine. It is very effective, and less prone to side effects than methadone, so it requires much less monitoring. It used to require a special license (which I got), but since the Mainstreaming Addiction Treatment Act became law in 2023, buprenorphine can be managed by any physician with appropriate training.
Buprenorphine is kind of a hybrid between a blocker like naltrexone and a substitution therapy like methadone. It stops withdrawals the way methadone does, but someone who has buprenorphine in their system cannot get high from regular opioids. Unless the patient is pregnant I prescribe buprenorphine in combination with the opioid blocker naloxone. You may know this combination of medications by the brand name Suboxone. The naloxone ingredient is there to prevent people from abusing the medication; it only becomes active if the medication is tampered with.
What to expect at a visit
Patients who see me for MAT come in for a first consult visit, where we make a plan. If the patient is actively withdrawing, I will make every effort to get them in as soon as possible. Most of the time that’s the same or next business day. If we wind up going with buprenorphine I will typically see the patient every 7 days while we find the right dose for them, and then space out visits. For the long term I see patients once a month either for buprenorphine monitoring or naltrexone injections, to make sure their medication is still working, and that it is still safe for them to take. Part of monitoring is testing for other drugs like cocaine that aren’t safe to mix with their prescriptions.
Most people stay on buprenorphine indefinitely. Remember that substitution therapy does not reverse the underlying dependence on opioids, so someone who stops buprenorphine cold turkey should expect the withdrawals and cravings to come back. If for some reason the patient does need to stop, we work together to plan how to taper off. I’ll still want to keep monitoring the patient for at least a month afterward, because the risk of relapse during that time right after treatment stops is very high.
These treatments don’t work for everyone. Some patients need more specialized care than I can offer. In those cases I may recommend intensive outpatient therapy, a partial hospitalization program, inpatient rehab, a methadone program, or another service with an addiction medicine specialist.
I’m first and foremost a primary care doctor, so when someone joins Presence to get help with opioids, I become their primary care doctor too. Often people who have been suffering haven’t been taking care of their health for quite some time and there’s a lot of work to do to get them healthy. That is also why MAT doesn’t cost a special fee at Presence; it is all part of membership. For some patients, MAT is primary care.
To learn more about whether Presence Primary Care is right for you, schedule a free Discovery Call with Dr. Mirer.
