Additional Staffing Among Top Requests By Providers Offering Medication-Assisted Treatment
We’ve all seen the distressing headlines over the past few years: overdose deaths spiked after the emergence of COVID-19 in 2020, then tapered slightly later that year. Researchers identified increased drug use, higher risk conditions such as isolation, and a more lethal drug supply as prime contributors.
Data suggests America’s overdose epidemic continues to worsen. Mortality data through the first half of 2021 released by the Centers for Disease Control and Prevention suggests that overdose deaths spiked again at the end of 2020, reaching their highest levels in March 2021 and staying there through June. The American Medical Association says the epidemic affects every state and that more than 107,000 deaths were reported in the U.S. between December 2020 and December 2021.
Frustratingly, we have evidenced-based treatment for opioid use disorders: medication-assisted treatment (MAT), which uses FDA-approved medicines such as buprenorphine, methadone, and naltrexone. However, less than 10% of people nationwide with opioid use disorder receive treatment. Perhaps more distressingly, less than 30% of residential treatment centers offer MAT for those using opioids improperly. This lack of access to treatment underscores the profound importance of offering MAT in primary care settings.
SSVMS conducted a survey of providers in Sacramento County already providing MAT services to understand more thoroughly how buprenorphine is currently being used, what the continued barriers are to expanding MAT, and what Sacramento medical providers feel would address these barriers. While the respondent number was small, 28 medical providers, there are important learnings from the survey when taken in the context of other national and statewide research.
The major findings can be grouped into three themes: motivation for providing MAT services; clinical perspectives and practices; and barriers and solutions to expanding MAT services.
Providers who engage in medication-assisted treatment are doing so primarily to provide care to those in need (81%) and respond to the need in the community (75%). While this may not be surprising, it is affirming. Physicians and other medical providers who are providing MAT are overwhelmingly doing so to meet the changing needs of the community served.
As Dr. Ben Morrison said in the workshops he conducted for this program, “If you’d asked me 10 years ago if I’d be treating opioid use disorder now, I would have said you were crazy. But we do what our patients need, what our community needs.”
Buprenorphine is being used for both pain management and opioid use disorder by 71% of the providers who responded. This is consistent with The AMA’s Substance Use and Pain Care Task Force’s evidence-based recommendations for policymakers and physicians to help end the nation’s drug-related overdose and death epidemic. Almost four out of five of those providers prefer to prescribe buprenorphine over alternative compounds, and most have patients sign a controlled substance agreement and conduct random urinalysis testing (74%). Almost all providers (91%) check CURES reports before prescribing buprenorphine.
Interestingly, respondents to the survey indicated higher satisfaction with buprenorphine for treating opioid use disorder (7.6 on a satisfaction scale of 1-10) than for treating chronic pain (6.3).
Respondents were mixed on the impact of telehealth on opioid use disorder and MAT. About half indicated they believe telehealth has worsened adherence to MAT and had led to increased relapses, with the other half felt telehealth had led to higher adherence and increased access to MAT.
“Telehealth is better, much easier for patients, follow-up rates are higher, and I’m able to do more home inductions,” one provider wrote. Despite the nearly even split, this positive observation is more consistent with the most recent research on telehealth-based MAT services.
The most robust answers to the survey were in regard to barriers that limit expanding MAT services to more patients. The top three cited were lack of adequate team support (nurses, care managers, behavioral health clinicians); time constraints; and lack of institutional administrative support, such as altered scheduling templates for MAT patients and space for inductions.
All three of the top barriers are clearly inter-related, in that they all speak to a lack of sufficient staff support and time. Not surprisingly, what respondents said would address these barriers was more support. These providers said their greatest staff needs included:
A staff member who is dedicated to MAT patients (care coordination)
Staff dedicated to rooming MAT patients
Staff to do outpatient and education for MAT patients
More support staff to assist with inductions
More staff to do phone follow up with patients
More help hiring and training staff to work with MAT patients.
Providers also said they need more time to schedule templates and to talk with MAT patients, especially during initial consults. They also want more time for induction appointments and to follow up by phone.
In addition to these strategies to expand MAT availability, respondents also identified the need for continued de-stigmatizing of addiction and addiction treatment. Educational materials for patients, welcoming clinic and office environments for patients with chronic pain or opioid use disorder, and having patients who have used buprenorphine to talk to other patients who might consider it are important toward encouraging patients to overcome their hesitations about treatment.
These survey findings are heartening, in that they demonstrate the deep commitment of Sacramento County providers to provide care to those suffering with opioid use disorder. The findings also underscore the importance of sufficient support staff and time toward providing the best MAT care.
The Sacramento Sierra Sacramento Valley Medical Society is deeply committed to ending the overdose epidemic and has served as the chair organization for the Sacramento County Opioid Coalition since 2017. In early 2022, The Substance Use Prevention and Treatment Department of Sacramento County provided funding to SSVMS to promote MAT services for pregnant women with opioid use disorder.
Over the course of six months, SSVMS and the Opioid Coalition hosted 11 live CME workshops at medical groups and in private physician offices on how to reduce the stigma associated with addictive disorders, enhance patient motivation for substance use treatment (specifically medication-assisted treatment), and the provider’s role in MAT.
Training sessions are available on demand at cmadocs.org/webinars. A series of educational videos have also been produced to help providers learn how they can use evidenced-based communication skills with pregnant women who have opioid use disorder. To complement these tools, SSVMS has created patient-facing flyers that promote MAT services and are designed to reduce the stigma experienced by pregnant patients suffering from opioid use disorder. The videos and flyers are available at sacopioidcoalition.org/mat-program or by contacting Lauren Werner at lwerner@ssvms.org.
