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Teaching residents to prescribe buprenorphine for opioid use disorder: Insights from a community-based residency program

Published:September 13, 2021DOI:https://doi.org/10.1016/j.jsat.2021.108621

      Highlights

      • The opioid overdose crisis demands increased physician resources to prescribe medical treatment
      • Residencies have room to improve addiction curriculum to better respond to the opioid overdose crisis
      • Family doctors are well-situated to respond to the opioid overdose crisis
      • Placing patients receiving medical treatment for opioid use disorder into residents’ primary care panels increases their prescribing practice after graduation
      • Covid-19 allowed for more virtual collaboration between patients and their families, residents and attendings

      Abstract

      Introduction

      Despite the impact of the opioid overdose crisis on the United States, few physicians are trained to provide treatment with buprenorphine. While research has described some factors contributing to comfort in providing buprenorphine treatment, more research is needed to identify optimal strategies to produce physicians who prescribe this medication.

      Methods

      A community-based family medicine residency in Massachusetts sought to improve residents' comfort with prescribing buprenorphine by integrating patients treated with buprenorphine directly into resident continuity clinic panels in addition to existing mandatory didactic teaching.

      Results

      The program saw a significant increase in buprenorphine prescribing among residency graduates three years after graduation after integration of patients on buprenorphine into resident continuity panels.

      Conclusion

      Efforts to further increase the number of graduates prescribing buprenorphine nationwide should emphasize supervised management of patients treated with buprenorphine during residency.

      Keywords

      1. Introduction

      The opioid overdose crisis continues to wreak havoc on communities across the United States with more than 90,000 overdose deaths per year (
      NCHS data brief (data brief no. 329): Drug overdose deaths in the United States, 1999–2017.
      ;
      Substance Abuse and Mental Health Services Administration
      Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health (HHS Publication No. PEP20-07-01-001, NSDUH Series H-55).
      ). Despite the excellent evidence supporting the three FDA-approved treatments for opioid use disorder (methadone, buprenorphine, and extended-release naltrexone)—in particular with regard to prevention of infectious sequelae like HIV and hepatitis C, overdose, and death—only 18.1% of the approximately 2 million people suffering from opioid use disorder are receiving these FDA-approved treatments (
      Substance Abuse and Mental Health Services Administration
      Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health (HHS Publication No. PEP20-07-01-001, NSDUH Series H-55).
      ;
      • Lipari R.
      • Park-Lee E.
      • Van Horn S.
      American's need for and receipt of substance use treatment in 2015.
      ;
      • Bositis C.
      • St. Louis J.
      HIV and substance use disorder- role of the HIV physician.
      ). A recent study showed that residency preparation in treatment of opioid use disorder is highly correlated with provision of such treatment in practice (
      • Tong S.T.
      • Hochheimer C.J.
      • Peterson L.E.
      • Krist A.H.
      Buprenorphine provision by early career family physicians.
      ). Early-career family physicians increasingly provide buprenorphine but still lag behind psychiatry and continue to constitute a small percentage of buprenorphine prescribers (
      • Lipari R.
      • Park-Lee E.
      • Van Horn S.
      American's need for and receipt of substance use treatment in 2015.
      ;
      • Rosenblatt R.A.
      • Andrilla C.H.
      • Catlin M.
      • Larson E.H.
      Geographic and specialty distribution of US physicians trained to treat opioid use disorder.
      ). Family physicians are uniquely positioned to support patients with treatment of their substance use disorders (
      • Lipari R.
      • Park-Lee E.
      • Van Horn S.
      American's need for and receipt of substance use treatment in 2015.
      ;
      Morbidity and Mortality Weekly Report: MMWR
      Trends in deaths involving heroin and synthetic opioids excluding methadone, and law enforcement drug product reports, by census region - United States, 2006–2015.
      ). As the patient's primary care provider, they have intimate knowledge of the intersection of the patient's mental and physical health problems, allowing them to provide holistic, patient-centered care. Additionally, family medicine residents are geographically distributed across rural and urban environments, which allows for access to care in regions with traditionally poor specialty penetration (
      • Ruddy G.
      • Fryer E.
      • Phillips R.
      • Green L.
      The family physician workforce: The special case of rural populations.
      ). Lawrence Family Medicine Residency has enriched its addiction medicine curriculum, which has led to an increase in buprenorphine prescribing among its graduates.
      Data from the American Board of Family Medicine shows that residents at the Lawrence Family Medicine Residency in Lawrence, Massachusetts, had a significant increase in buprenorphine prescribing practices after initiating an addiction medicine curriculum that includes DATA 2000 DEA-X waiver training to prescribe buprenorphine as well as longitudinal care of patients on buprenorphine treatment under the supervision of a faculty member. Residents received this training during an afternoon didactic and then were assigned patients receiving buprenorphine in their primary care panels. This report examines the foundational components of the Lawrence Family Medicine Residency Addiction Medicine curriculum and posits that enhanced curricular training in addiction medicine is associated with increased prescribing practices years after graduation.

      2. Methods

      Beginning in 2006, the Lawrence Family Medicine Residency integrated into its curriculum formal didactic teaching on the management of substance use disorders. The curriculum placed a particular emphasis on opioid use disorder given the relatively high incidence in the community. The residency program integrated a number of different educational opportunities, including formal didactic teaching, DEA-X waiver training, clinical shadowing, and longitudinal management of patients on buprenorphine, over the course of six years.
      The program integrated a four-hour formal lecture, the “Substance Abuse Symposium,” into the first year resident longitudinal didactic session beginning in 2011. This lecture was preceded by shorter lectures that began in 2006. The longer session, taught by a multidisciplinary faculty such as family medicine physicians, behavioral health specialists, and nurses, broadly focused on the management of substance use disorders in the primary care setting.
      The residency program integrated mandatory DEA-X waiver training into the second year resident longitudinal didactic curriculum beginning in 2011. This session was taught in a “half and half” format as produced by the American Society of Addiction Medicine and co-taught by the director of the clinic's Outpatient Based Addiction Treatment (OBAT) Program and the medical director of a local methadone outpatient treatment program. Through this training, 100% of residency graduates completed the requirements to apply for the DEA-X waiver to prescribe buprenorphine upon graduation.
      Family medicine attending physicians began shadowing patients being treated for opioid use disorder in 2011. This shadowing included patients in conventional one-on-one physician visits (starting in 2012) as well as in a group setting (starting in 2011). This experience was elective and not all resident physicians took part. Of those who did access this experience, they were able to shadow 2–3 times during residency training.
      In 2007–2009, beginning as a pilot program and expanding to all residents in the graduating class of 2014, the program integrated patients on buprenorphine into resident continuity clinic patient panels. Prior to 2014, the experience was ad hoc and often accessed by only 1–2 residents in each class. Beginning in 2014, each resident managed 2–5 patients over the course of their residency, closely supervised by an experienced attending physician. Supervision of these resident visits is conducted primarily by a core group of 6–7 attending family physicians who themselves care for large practices where patients receive buprenorphine. In addition, all core faculty and most community faculty possess the DEA-X waiver, allowing them to supervise visits while consulting with more experienced faculty for complex aspects of care. We show all of these curricular innovations in Fig. 1.
      Fig. 1
      Fig. 1Timeline of residency buprenorphine training innovations.
      We used data from the 2016, 2017, 2018, and 2019 National Family Medicine Graduate Surveys. The survey is administered annually by the American Board of Family Medicine (ABFM) to all diplomates who graduated from residency in the three years prior (
      • Mitchell K.B.
      • Maxwell L.
      • Miller T.
      The National Graduate Survey for family medicine.
      ). Our data included both national survey results as well as the survey results specific to the graduates of the Lawrence Family Medicine residency program. We reviewed responses to two questions pertaining to prescribing buprenorphine for the treatment of opioid use disorder. These questions asked residents: 1) Did residency prepare you to prescribe buprenorphine (yes or no), and 2) do you currently prescribe buprenorphine (yes or no). The study team completed descriptive statistics using Microsoft Excel. The American Academy of Family Physicians Institutional Review Board approved this study.

      3. Results

      The response rate for each year of the national survey was 67–68%, with 8980 total respondents. The response rate for the Lawrence Family Medicine Residency was 78–100%, with 25 total respondents. Our data show that, compared to the national sample, more graduates of the Lawrence Family Medicine Residency felt adequately prepared to prescribe buprenorphine on graduation. The percentage of residents who responded “yes” to this question was 71% (graduating class of 2013), 86% (graduating class of 2014), 86% (graduating class of 2015), and 75% (graduating class of 2016). These numbers are in comparison to the national responses of 10%, 9%, 11%, and 12%, respectively (Fig. 2) .
      Fig. 2
      Fig. 2Results - Percentage of graduates currently prescribing buprenorphine.
      More important than preparing residents to prescribe buprenorphine is the rate of prescribing in practice. The percentage of residents who responded that, three years after residency graduation, they were prescribing buprenorphine in their practice was 14% (graduating class of 2013), 71% (graduating class of 2014), 86% (graduating class of 2015), and 100% (graduating class of 2016). These numbers are in comparison to the national responses of 7%, 9%, 13% and 12%, respectively. The sharp increase in prescribing practices is temporally associated with the implementation of longitudinal management of patients on buprenorphine in resident continuity clinic panels, as we described above.

      4. Discussion

      4.1 Lessons learned

      The Lawrence Family Medicine Residency program integrated patients with opioid use disorder into residents' primary care panels, which prepared residents to prescribe buprenorphine and increased self-reported prescribing practices after graduation. Residents on average currently have 3–5 patients receiving buprenorphine on their panels, which translates to several opioid use disorder visits per month. This volume enriches their ability to coordinate with community partners (including peer recovery networks), co-manage dual diagnoses, and provide consultative care for other patients on their patient-centered medical home (PCMH) team. Furthermore, the residency program makes every effort to involve residents in patients' initiation on buprenorphine and to then have the residents continue to follow those same patients for maintenance visits. This approach helps to build a rich repertoire of clinical skills invaluable to post-residency practice that go far beyond the skills acquired by simply obtaining a DEA-X waiver. Other scholarship has shown that most residency curricula for the treatment of opioid use disorder focus almost entirely on DEA-X waiver training (
      • Graddy R.
      • Accurso A.J.
      • Nandiwada D.R.
      • Shalaby M.
      • Holt S.R.
      Models of resident physician training in opioid use disorders.
      ). We posit that our program has been successful because it produces physicians who treat opioid use disorder in practice, which is directly related to our program's integration of patients receiving buprenorphine into residents' continuity clinic panels. We recommend that this approach be considered an evidence-based approach to increasing the total number of graduates who go on to provide this life-saving medication in practice (Table 1) .
      Table 1Survey question results.
      Question2016 national2016 program2017 national2017 program2018 national2018 program2019 national2019 program
      Did residency prepare you to prescribe buprenorphine?203 (10%)5 (71%)190 (9%)6 (86%)243 (11%)6 (86%)292 (12%)3 (75%)

      4.2 Challenges

      Because residents lack the ability to independently prescribe buprenorphine, they are dependent on their attendings to prescribe the medication for them. By encouraging all our faculty to obtain DEA-X waivers, the program has made it much less burdensome for residents than it might be if only one or two faculty were to have the waiver. Nevertheless, the clinical workflow is encumbered by this issue and may lead to delays in care.
      Furthermore, comfort with buprenorphine varies widely across such a large group of prescribers and so residents encounter differing management styles and opinions. Lack of evidence-based practices around when and how to lengthen buprenorphine prescription intervals, how to connect patients to services, and how to address time-sensitive questions to the 6–7 experts in the clinical system continues to challenge the curricular experiences and can cause stress to learners. The program highly encourages pre-visit planning, but such planning can be difficult with residents' busy and highly variable schedules.

      4.3 Next steps

      The impact of COVID-19 on clinical care in the United States has led to dramatic changes in the management of opioid use disorder, as the federal government has significantly liberalized a number of restrictions around buprenorphine prescribing. Our residency program is now faced with how to return to a pre-COVID approach to practice, as many residents have learned how to manage buprenorphine in an exclusively telehealth environment without ready access to drug testing and without a firm emphasis on risk reduction.
      Apart from the changes that the COVID-19 pandemic brought, our residency program has a number of important next steps to take in our approach to teaching residents how to treat opioid use disorder. Given our practice environment (i.e., the majority of physicians possess DEA-X waivers and a large number of patients are on buprenorphine), our program needs to ensure that residents who go on to practice in environments that are less welcoming to addiction medicine are nevertheless well-supported. Such residents may be charged with creating entire systems to manage a buprenorphine practice and may not benefit from local expert consultation with difficult or complex cases. Focusing on identifying resources for those in practice (including local organization such as the Massachusetts Consultation Service for the Treatment of Addiction and Pain [MCSTAP] and national organizations such as the Provider Clinical Support System [PCSS] and the wealth of resources provided by the American Society of Addiction Medicine [ASAM]) will be an exceptionally important component of preparing those residents for independent practice. Finally, family medicine residencies nationwide must work with national organizations (notably the Association of Family Medicine Residency Directors [AFMRD]) to ensure that competence in prescribing buprenorphine is included and described as an entrustable professional activity.

      Declaration of competing interest

      No conflicts of interest to report.

      Acknowledgements

      We acknowledge the American Board of Family Medicine for administering the Graduate Survey and providing us with our results.

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