By M. Shoaib Khan, MD, AAHIVS
A 17-year-old died of a fatal opioid overdose in our rural California town, and I felt responsible.
Medication assisted therapy (MAT) with buprenorphine has been shown to be a lifesaving treatment for opioid use disorder in that it stops patients from having cravings and withdrawals and helps in preventing drug overdose-related deaths1. I am one of the only physicians in a 50-mile radius able to prescribe buprenorphine for patients under the age of 18 years. This 17-year-old had died while I was on vacation, and when I heard the news of his passing, I thought that maybe if I had not gone on vacation, he might still be with us.
While we have all been preoccupied with the Covid pandemic for the past two years, the opioid epidemic has also gotten worse2. Preventable overdose-related deaths continue to rise, especially in the poorest and more rural communities3. The story of my patient’s death is way too common – and that needs to change.
Federal and State governments have already taken several steps to reduce barriers to accessing buprenorphine4. However, organizational hesitancy in allowing prescribers to take-on “addiction care” that is often considered out of scope for primary care physicians, understocking at pharmacies, insurance denials, and adequate physician staffing continue to decrease patients’ access. More physicians must be well-trained and confident in providing MAT for opioid use disorder in all age groups, including teenagers and young adults5. We must enable them to do so.
The lack of practical prescribing experience during residency prevents many graduates from developing the confidence necessary to prescribe after training. At UCSF Fresno, we have implemented a mandatory harm-reduction clinic curriculum for all Family Medicine residents. We conducted a needs assessment which identified five essential components: induction with and later maintenance on buprenorphine, taper off opioids and benzodiazepines, addiction care as chronic care, and conflict management skills. Residents shadow in a high-volume clinic, discuss more complex patient cases with an attending, review the literature, and have multiple observed clinical exams. We are evaluating the curriculum by measuring pre- and post- knowledge and confidence levels for all residents; we plan to follow graduates in one year to see how many use these skills. We aim to improve each resident’s level of confidence prescribing buprenorphine and hope that this will increase their likelihood of practicing these skills once they graduate.
With the CAFP, we are calling for all California Family Medicine residency programs to institute a similar curriculum. As a patient once shared with me: if we do not make buprenorphine as readily available as the illicit drugs, we will continue to see preventable deaths in our communities.
About the author: M. Shoaib Khan, MD is an Assistant Clinical Professor of Family and Community Medicine, UCSF Fresno. He works as an addiction and HIV specialist at the United Health Centers of San Joaquin Valley.