Note: This is adapted from a column that originally appeared in the Winter 2017/2018 edition of Fort Wayne Medicine Quarterly.
Well, I did it. I got my buprenorphine waiver to provide office-based medication-assisted treatment (MAT) for drug and alcohol addiction.
The Substance Abuse and Mental Health Services Administration (SAMHSA) website
has a number of choices for training. Most are eight-hour trainings either online only or both online and in person. I took the course “Buprenorphine Waiver Training at the American Academy of Addiction Psychiatry” completely online; it included legislation, pharmacology, safety, patient assessment and more. You have to complete all of the modules and the post-test within 45 days of starting. You get three attempts to pass, and I passed on the first try.
Screening for drug and alcohol addiction in your practice is not as hard as you’d think. Let’s begin by clarifying the ever-expanding terminology.
Alcohol Use Disorder (AUD):
AUD is a chronic, relapsing brain disease characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational or health consequences. AUD can range from mild to severe, and recovery is possible, regardless of severity. The Diagnostic and Statistical Manual (DSM) integrates alcohol abuse and alcohol dependence into this single disorder with mild, moderate and severe sub-classifications.
This term refers to intentional or unintentional use of a prescribed medication in a manner contrary to directions, regardless of whether a harmful outcome occurs. Misuse can include not taking the medication according to the prescription, unsanctioned use (running out early; bingeing), altering the route of delivery (injecting, crushing tablets, snorting, chewing), accessing drugs from other sources, drug-seeking behavior and reluctance to use other methods of pain management.
This term refers to intentional or unintentional use of legitimately prescribed medication in an un-prescribed manner for its psychic effect, deciding to increase one’s own dose, unknowingly taking a larger dose than directed, a suicidal attempt or gesture or inadvertent poisoning. The term implies usage for reasons other than those indicated in the prescribing literature or for other off-label uses.
Abuse is the self-administration of medications to alter one’s state of consciousness. This is an intentional, maladaptive pattern of using a medication, whether legitimately prescribed or not, leading to significant impairment or distress. That can mean repeated failure to fulfill role obligations, recurrent use in situations in which it is physically hazardous, multiple legal problems or social and interpersonal problems over a 12-month period.
Addiction is a primary, chronic, neurobiological disease with genetic, psychological and environmental factors influencing its development and manifestations. It is characterized by impaired control over drug use, compulsive use, continued use despite harm, or craving.
Substance Use Disorder (SUD):
This is a condition involving the intoxication with, withdrawal from, abuse of or dependence upon a substance (including alcohol) with defined potential for abuse or dependence that meets the criteria for clinical diagnosis delineated by the current DSM or the International Classification of Diseases (ICD).
Opioid Use Disorder:
This refers to a problematic pattern of opioid use to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: taking opioids in larger amounts or over a longer period than intended; persistent desire or unsuccessful efforts to cut down or control opioid use; spending a great deal of time in activities necessary to obtain or use the opioid or to recover from its effects; craving, or a strong desire or urge to use opioids; recurrent opioid use resulting in a failure to fulfill major role obligations at work, school or home; continued opioid use despite persistent or recurrent social or interpersonal problems caused or exacerbated by opioids’ effects; forgoing or reducing important social, occupational or recreational activities because of opioid use; recurrent opioid use in situations in physically hazardous situations; continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem likely to have been caused or exacerbated by the substance; tolerance, as defined by either a need for markedly increased amounts of opioids to achieve intoxication or desired effect or an effect that markedly diminishes with continued use of the same amount of an opioid (Note: This criterion is not considered to be met for those taking opioids solely under appropriate medical supervision.); withdrawal, as manifested by the characteristic opioid withdrawal syndrome or the taking of opioids or a closely related substance to relieve or avoid withdrawal symptoms.
Based on 2010 data according to SAMSHA, for every one opioid overdose death, 115 people abuse or are dependent on opioids, and 733 engage in nonmedical use. So, a significant number of people in your practice may be misusers or nonmedical users of opioids. The good news is that brief interventions may keep many of these people from progressing to abuse or substance use disorder.
I don’t want to forget alcohol use disorder, both because it is common and because, with a buprenorphine waiver, you can easily treat it in your office. According to the 2015 National Institute on Alcohol Abuse and Alcoholism, 6.2 percent of Americans age 18 or older – 15.1 million adults – had AUD. This includes 8.4 percent of men (9.8 million people) and 4.2 percent of women (5.3 million people) in this age group. Sadly, only about 6.7 percent of adults who had AUD in the past year received treatment.
Research shows that only 20 percent of primary care doctors describe themselves as very prepared to identify alcoholism or illegal drug use. This has to change. While patients may not always comply, they do value what you say, and you remain a very respected and integral part of a patient’s life. I call it “objective intimacy”; we have patients’ permission to ask questions and discuss issues that no one else can or will.
If you don’t identify when your patients are struggling with substance misuse or abuse of any nature – who will?
Note: This article expresses the personal views of the author and not ISMA.