The grandmother, tears in her eyes, had to look away as she whispered to her doctor what had happened. She had come across some oxycodone pills and relapsed into opioid use, decades after entering recovery. “I need help,” she said.
But her doctor, internist Audrey M. Provenzano, couldn’t prescribe the addiction treatment the patient wanted to try — buprenorphine — because she had not obtained the necessary federal certification.
Provenzano was hardly unusual: Few primary care doctors can prescribe buprenorphine, and few feel prepared to treat addiction in their patients.
But as the doctor reveals in a moving essay in the Feb. 15 New England Journal of Medicine, such a failure to help with a common affliction can have dark consequences.
She referred her patient, whom she calls “Ms. L.,” to a colleague who could prescribe buprenorphine, but the decision seemed to fray the doctor-patient bond. Ms. L. stopped coming to appointments, and a year and a half ago, Provenzano learned that she had died of an overdose.
“Ms. L. and I had had a relationship,” Provenzano wrote. “She had trusted me. And I’d turned her away.”
Saddened and ashamed, Provenzano decided to undergo the eight-hour training that authorizes her to prescribe buprenorphine, best known by the brand name Suboxone. The drug helps to stop cravings and blocks overdoses.
Now working at Massachusetts General Hospital’s Chelsea HealthCare Center, Provenzano treats a small group of patients with opioid use disorder. And she wrote the essay to call on her colleagues to do the same.
It’s a call that has already gone out in Massachusetts. A state commission has been urging primary care practices to take on the challenges of treating addiction, Boston Children’s Hospital is helping community pediatricians embrace addicted adolescents, and many community health centers are starting to integrate addiction treatment into primary care.
“It’s not an easy disease to treat,” said Dr. Marcelo Campos, a rare doctor in private practice who prescribes buprenorphine. “But this is a challenge we are facing right now. I think it is imperative for us to learn.”
While some doctors are stepping up, many hesitate — unschooled in addiction treatment and daunted by the complexities such patients bring.
Buprenorphine is one of three medications that can control the craving for opioids; doctors are permitted to prescribe it only after taking a course. (The other treatments are methadone, which is dispensed at federally regulated clinics, and Vivitrol, a long-lasting injection of naltrexone, which does not require special training.)
Nearly 3,000 doctors, nurse practitioners, and physician assistants in Massachusetts have undergone the buprenorphine training, according to the US Substance Abuse and Mental Health Services Administration. But it’s not known how many work in primary care or are prescribing the medication.
In her essay, titled “Caring for Ms. L. — Overcoming My Fear of Treating Opioid Use Disorder,” Provenzano is frank about why she initially shied away from buprenorphine. She didn’t have the energy for the eight-hour training after her long days at work. But also, she admits, “I did not want to deal with the patients who needed it.”
She had witnessed addicted patients harassing secretaries and nurses and trying to game urine tests for drug use. By definition, addiction impairs behavior in troubling ways.
“Already overwhelmed, I did not want to take on patients with needs I did not know how to meet,” she writes.
When she did begin treating addicted patients, Provenzano found them challenging and complex, often burdened with other mental and physical illnesses and disrupted families.
The solution, she says, is not for doctors to turn their backs on such patients, but to work to form teams of social workers, psychologists, and others who can support their efforts.
Provenzano’s health center provides such services, and across the state, to varying degrees, other community health centers are taking the lead on integrating addiction treatment, said Kerin O’Toole, spokeswoman for the Massachusetts League of Community Health Centers. Of the 515 physicians who work at the 50 community health centers in Massachusetts, 200 are authorized to prescribe buprenorphine, according to O’Toole.
In contrast, at Atrius Health, a large medical group in Eastern Massachusetts, some 340 physicians work in internal medicine or behavioral health. But only seven of them prescribe buprenorphine.
One of them is Campos, whose office is in Boston’s Post Office Square. Like Provenzano, he was moved by a death. Shortly after Campos started working at Atrius, a 27-year-old patient died of an overdose. He never even knew she had been using drugs.
Campos, who had previously obtained certification to prescribe buprenorphine, started offering it at Atrius and now has about 40 to 50 patients receiving it. He requires them to undergo counseling as part of their treatment.
“I try to see all these patients the same way I see my patients with chronic medical problems,” Campos said. “They are not any different. If you start to have that mind-set . . . you see them with a different set of eyes.”
When Dr. Kate Atkinson started offering buprenorphine in her Amherst family practice a decade ago, patients who needed it “came out of the woodwork,” she said. Some had been afraid to reveal they were addicted and needed help. Some were getting treatment at a clinic but had never told their own doctor.
Among her opioid-addicted patients are “lots of VIPs, deans of colleges, heads of departments, people that didn’t want other people to know,” Atkinson said. In the regular doctor’s office, “No one knows why you’re sitting in the waiting room,” she said.
The protocols for buprenorphine, which include urine screening and pill counting to monitor drug use, are no more burdensome than those for diabetes or asthma drugs, she said.
“If every one of us took 50 patients [with opioid addiction] in our private practice, it would not be a big problem,” said Atkinson, who estimates that about 2 percent of her patients have opioid use disorder. “All people in primary care should offer it. . . . We’re saving lives with Suboxone.”
It’s starting to happen in Massachusetts.
The Health Policy Commission, a state agency that monitors medical costs, has pushed primary care practices to offer medication-assisted treatment for opioid use disorder, and 38 groups have done so, although it’s not clear whether all offer buprenorphine.
Boston Children’s Hospital is working with pediatricians to introduce buprenorphine for addicted adolescents; so far two practices are involved and others are waiting in line, said Dr. Sharon Levy, who heads the program.
And Dr. Michael F. Bierer, who has been prescribing buprenorphine since 2002 as part of his internal medicine practice at Massachusetts General Hospital, says he is no longer the only one at his hospital.
“The worry about prescribing is overblown before you kind of take the first plunge and do it,” Bierer said. “Then the rewards are very rich.”
Indeed, Provenzano and others said taking care of people with opioid addiction is meaningful and satisfying work.
Campos describes it this way: “Patients come in here, they are completely destroyed. In a matter of weeks, they are completely transformed. Very few things we do in primary care are this rewarding.”Felice J. Freyer can be reached at firstname.lastname@example.org. Follow her on Twitter @felicejfreyer.