Audrey Provenzano, MD, MPH, a primary care physician in Chelsea, Mass., avoided getting the waiver needed to prescribe buprenorphine (Suboxone), and so was unable to treat an opioid-addicted patient who subsequently died of an overdose. She wrote about this experience in a moving piece .
We discussed that story, medicine's stormy history with opioid abuse, and the politics of the buprenorphine "waiver" in a Doc-to-Doc video conversation.
Transcript:
Dr. Perry Wilson: Dr. Audrey Provenzano is a primary care doctor at the Chelsea Health Center affiliated with Mass General Hospital in Boston. She's also the producer and host of The Review of Systems podcast, which covers a wide range of primary care topics, from innovations to healthcare policy. Her recent piece in The New England Journal of Medicine is entitled "Caring for Ms. L – Overcoming my Fear of Treating Opioid Use Disorder." Dr. Provenzano, thanks for joining me on Doc 2 Doc.
Dr. Audrey Provenzano: Thanks for having me.
Dr. Wilson: Your New England Journal piece tells the story of Ms. L., with whom you had a long primary care relationship until she came to you with a new problem. Tell us what happened then.
Dr. Provenzano: Sure. I met her a couple of years before, maybe a year and a half before, and she had, like so many of my patients, a number of chronic diseases: diabetes, high blood pressure. But I don't know. She was just one of those patients who we just had an easy relationship, and I loved seeing her. She had a history of opioid use disorder, but it just never came up. She had been in remission for decades, for a really long time, and she relapsed and came to me and asked to start Suboxone. I couldn't at the time. I was not waivered, which was a conscious choice. I just didn't feel equipped. I felt guilty about it, but I just didn't feel like I could handle it and that I knew how to care for those patients. I referred her to a colleague who really provided excellent care for her. I just wrote about that experience.
Dr. Wilson: Before we get into what happened with Ms. L, for those physicians who aren't as familiar with Suboxone or buprenorphine, can you describe the waiver process and the reasoning behind it?
Dr. Provenzano: Oh, sure. Buprenorphine came out I think around 2000 or 2001, and it's meant to treat opioid use disorder. It stimulates the same receptors in the brain as other opioids do, but the pharmacokinetics are such that it doesn't produce any kind of sensation of feeling high. It just helps people feel normal. It's because of the stigma and probably some other policy reasons, it's pretty highly regulated, so you have to get a waiver to prescribe it, which is an 8-hour online course and then taking an exam. There are a lot of courses that you can go to as well, but I did mine online. The pharmacokinetics of it are really straightforward, but I think that that additional barrier of having to get waivered certainly contributed to my hesitation about it, and I think probably other physicians in the community as well.
Dr. Wilson: Yeah, it seems eight hours is not excessive, but nevertheless, that's a hurdle for those of us who are pretty busy day to day to jump. I would tend to agree. By engaging in that, you're sort of saying, "Okay, I'm going to start doing this. I'm going to start treating opioid use disorder."
On the other hand, the existence of this course and a waiver and special certification, in some ways, provides what seems like a convenient excuse. I can look a patient in the eye and say, "Gosh, I'd love to help. I'm not legally allowed to prescribe this drug. Let me refer you elsewhere." Do you think that docs are embracing that excuse? Is the sort of need for certification, does it allow them to potentially not deal with a problem that is obviously hard to deal with? This opioid use disorder is an incredibly difficult condition to treat. In other words, is it more than just the time commitment? Is it a fear of engaging in that treatment paradigm?
Dr. Provenzano: I can't speak for anyone else. I mean all I can say is that it was a barrier for me, and it was, in a way, an excuse for me. I think that you think about the harm. Everything in medicine we talk about the benefits and the harms, right? I can prescribe enough opiates to snow all of Chelsea. [LAUGHTER] But I had to do this extra course to prescribe a lifesaving medication that actually is incredibly safe and can do more in a primary care setting to reduce mortality than I think almost anything else we can prescribe.
I think that, obviously, stigma plays a big role in all of those risk and benefit calculations, and the internal calculus that we all do about whether or not we get waivered. I think it's a complicated question. I think that it's a reasonable policy question to revisit about whether this waivering process is prohibitive, if it's appropriate, if there are ways that policy could be adjusted to make it easier for people to access care and make doctors feel less hesitation about prescribing this really safe lifesaving drug.
Dr. Wilson: I'm going to go back to Ms. L for a moment now. One of the things that really struck me is you have an affiliation with Mass General Hospital. There's no shortage of specialists that can help with her treatment, and you referred her to an excellent provider who was willing to treat her opioid use disorder. Yet, you wrote in your story that she never came back to you as her primary care doc after that moment, despite this long history together. What do you think happened there and how did that affect you?
Dr. Provenzano: Yeah. I should clarify to say that I met her at another job, so I met her at another clinic, but she never came back. I really think that it was just she felt so vulnerable about it, and as I say, it had literally almost never come up. It was on her problem list. I think maybe in our first visit we talked about it, but it just never came up. I think she'd been through a lot. I think she was really ashamed about her relapse, and it took a lot for her to come to me and ask for this, even though we had a pre-existing relationship. I think that just… I don't know. I don't know. Maybe it just fractured something for her. I think at that point her life was really complicated and obviously getting treatment for her opioid use disorder at that point was a lot more important for her than her diabetes and other issues. I don't know entirely what happened, but I think about her a lot, all the time.
Dr. Wilson: What did end up happening with Ms. L?
Dr. Provenzano: Yeah, she never came back. I had some follow-up appointments booked, but she never came back. She kind of, I think… I'm not entirely sure that the program that I had referred her to was a good fit and I think she maybe moved on to try other places. I kind of lost track of her, and then I think maybe a year and a half or two years later, she popped back up in the EMR. I was preparing for a clinic and just saw that she had been brought in and had died of an overdose.
Dr. Wilson: That must have been really, really difficult for you. It's always hard to lose a patient, but I think this, in particular, because of that added moment of referring her to someone else. I mean obviously an appropriate referral, but it comes across very clearly in what you wrote how sort of devastating that feeling was for you, maybe more so than when we lose other patients.
Dr. Provenzano: Yeah, it was absolutely devastating.
Dr. Wilson: Now you went ahead and that experience led you to go ahead and go through this course, and get the waiver to prescribe Buprenorphine. You're actively using this in your practice now?
Dr. Provenzano: Yeah, I see patients for it almost every day at this point. It's been an incredible journey. I've learned so much. I'm very lucky. In my practice, I have a colleague, Dr. Joe Joyner, who's addiction boarded and I can run things by him. There is an addiction psychiatrist on staff. We have a really wonderful recovery coach. I'm very lucky I'm surrounded by a lot of great resources, and there are places for me to refer patients who are really complicated and need people with more experience. [00:10:02] But I have been able to integrate opioid use disorder into my primary care practice really well, and I've really enjoyed it.
Dr. Wilson: What would you say to those primary care providers who maybe don't have that infrastructure near them, who they're in a solo practice or a small-group practice, they don't have addiction specialists nearby? Would you encourage them to get the waiver and start treating patients or do you think that backup is necessary?
Dr. Provenzano: Gosh, that's a hard question. I think it's a judgment everyone has to make for themselves. I would just say, again, that it's a really safe medication and if you're able to build a referral network in your community, I really urge people to consider it because I do think having some backup is important, especially at first. I did use the online program, the PCSS program. It's an online peer support program for people. You can sign up and get a mentor who you can run cases by over email or phone, and that was very helpful. Maybe for folks who don't work in an area where they can easily build a referral network, it's a good resource.
But I also think that we're not going to adequately meet the need of the opioid epidemic unless we are more active in primary care treating addiction, so I would encourage people to at least consider it.
Dr. Wilson: Do you have any clinical tips or pearls for people starting out using Buprenorphine? To physicians, I mean. Anything you've learned as you've started to treat patients that we should be aware of?
Dr. Provenzano: Gosh, I think the biggest one is learn from your patients. A lot of patients, when they come into treatment, they're very motivated and they know a lot about Suboxone and they've heard from friends and people who they know who are in recovery. Some probably have used some on the street, and so they know how it works. They know usually kind of what dosing is adequate for them. So the patient really… I mean, like always, are your best resource in trying to start someone on it, I think.
Dr. Wilson: Well, Dr. Audrey Provenzano, your piece in The New England Journal of Medicine, again, was incredibly touching. Thank you for sharing that with us. Thank you for trying to treat patients with this condition. I very much hope that your story inspires more doctors in primary care and in other specialties to go ahead and get this waiver and to learn about this drug, which actually may impact the opioid epidemic in the United States. Thanks, once again, for joining me.
Dr. Provenzano: Sure. Thanks so much for having me.