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Relying on Primary Care Physicians to Treat Opioid Use Disorder Fails Both Patients and Providers

The new DEA ruling is doing a disservice not only to people with OUD, but to the entire medical care system—exacerbating a condition that will most likely lead to death.

Primary care physicians are tired.

Covid-19 overburdened and overworked my PCP colleagues. In 2022, 62% of PCPs said they knew a clinician who retired early or quit during the pandemic—leading to a shortage of 180,400 physicians (if everyone seeking care was able to access it). But PCPs were in short supply in the U.S. even before the pandemic. In 2019, the U.S. Health Resources & Services Administration reported that the country needed an additional 13,758 primary care physicians to address the shortage of healthcare professionals in designated “healthcare deserts.”

Now, the Drug Enforcement Administration (DEA) wants to add a more dangerous burden to the shoulders of PCPs. In late February, the organization proposed permanent changes to federal telemedicine regulations. Among other regulations, these new rules would limit new telemedicine prescriptions for buprenorphine, an FDA-approved medication used to treat opioid use disorder (OUD), to a 30-day supply. Following this period, patients with OUD would need to visit a physician in-person in order to continue treatment. In many instances, this in-person visit would be with a PCP. The same PCP who is already experiencing burnout and staff shortages.

The DEA cites its proposed rules as progressive—a safe means of expanding healthcare access and telemedicine beyond pre-pandemic regulations. In reality, though, the rulings are quite dangerous.

Instead of making access to addiction treatment easier, the updated policies ignore the pleas of an already strained system. At a time when telemedicine OUD specialists are offering treatment options that are more successful than their in-person counterpart, the DEA’s proposal will only lead to patient (and practitioner) harm.

Successful OUD treatment requires time that most PCPs don’t have

Effective OUD treatment requires consistent attention and extensive training in the field, especially when treatment comes in the form of medication. A 2014 study showed that patients on a taper treatment plan (who were gradually coming off of medication) were 1.5 times as likely to return to illicit opioid use compared to patients on a maintenance treatment plan. Because successful medicated treatment for OUD requires continuous care, patients should have regular check-ins with their treatment provider, starting with visits few times a month and eventually monthly.

In our current healthcare system, PCPs often do not have the time to offer the quality of care that helps patients maintain this adherence. Already, patients struggle to get appointments with their physician. If they choose to have an in-person visit more than every three years as recommended, it’s typically at an irregular cadence and with a lengthy delay in care. 60% of patients wait 2 weeks to see their regular care provider and only 10% are able access care the same day. For patients who need to find a new PCP, the problem worsens: in 2022, the average wait time to get an appointment was 26 days—this timeframe could mean life or death for a patient with OUD.

Without consistent care, the risk of relapse and related emergency medical care for people with OUD increases greatly. Patients with poor buprenorphine adherence are nearly 3 times as likely to be hospitalized following treatment. And if patients new to treatment are limited to a 30-day supply of buprenorphine, approximately 9 out of 10 will return to active opioid use, according to a 2011 study.

OUD patients deserve specialists

Primary care doctors are equipped to handle the everyday struggles our patients face. Things like common colds or infections or chronic physical illnesses like diabetes and high cholesterol. But for other health issues, there are specialists; a PCP wouldn’t  perform brain surgery or a hip replacement, so why are they suddenly expected to be versed in long term OUD care (some are, but not all—addiction care is rarely taught at medical school).

I believe that specialists in addiction treatment—providers who have dedicated the time and effort to become experts—are the best providers for people with OUD. These providers already understand what effective treatment looks like and are equipped to handle a patient’s sometimes wavering journey to recovery. Accessing specialists to treat OUD can—and should—come in many forms, whether in-person or via telehealth. In fact, there is strong evidence from CDC, CMS, and NIDA researchers that indicates telehealth has improved retention for medication for OUD (MOUD).

The new DEA ruling is doing a disservice not only to people with OUD, but to the entire medical care system—exacerbating a condition that will most likely lead to death. The updated regulations are based on the assumption that people would receive better care from a PCP who knows their entire medical history and is deeply involved in their care. But OUD patients don’t need to turn to a PCP for care. They need someone with deep knowledge of the disorder who will dedicate the appropriate time to help them safely navigate their recovery. And they deserve a choice in how they work with them.

Photo: sorbetto, Getty Images
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Brian Clear, MD, FASAM, is a double boarded Family and Addiction Medicine Physician who has dedicated his career to the care of patients struggling with problematic opioid use. As Chief Medical Officer, he has designed and scaled Bicycle Health's telemedicine platform and continues to publish research finds that support the success of this model, ultimately working to contribute to destigmatization and improved provider understanding of effective accessible OUD care. 

Dr. Clear earned his Doctor of Medicine (MD) from American University of the Caribbean School of Medicine and completed his residency at the University of Kentucky Family & Community Medicine Residency Program with a focus on global health. Before Bicycle Health, Brian served as Medical Director for the integrated treatment of opioid use disorder and primary care services with BAART Programs in San Francisco.

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