NEJM primary care and the opioid-overdose crisis

Despite widespread awareness of the opioid overdose crisis, the epidemic continues to worsen. In 2016, there were 42,249 opioid overdose deaths in the United States, a 28% increase.

from the previous year. According to the National Center for Health Statistics, life expectancy in the United States dropped in 2016 for the second consecutive year, partly because of an increase in deaths from unintentional injuries, including overdoses. It was the first 2-year decline since the 1960s. How can we be making so little progress? In part, the overdose crisis is an epidemic of poor access to care. One of the tragic ironies is that with well-established medical treatment, opioid use disorder can have an excellent prognosis. Decades of research have demonstrated the efficacy of medications such as methadone and buprenorphine in improving remission rates and reducing both medical complications and the likelihood of overdose death.1 Unfortunately, treatment capacity is lacking: nearly 80% of Americans with opioid use disorder don’t receive treatment.2 Although access to office-based addiction treatment has increased since federal approval of buprenorphine, data from the Drug Enforcement Administration (DEA) reveal that annual growth in buprenorphine distribution has been slowing, rather than accelerating to meet demand (see graph). To have any hope of stemming the overdose tide, we have to make it easier to obtain buprenorphine than to get heroin and fentanyl. We believe there’s a realistic, scalable solution for reaching the millions of Americans with opioid use disorder: mobilizing the primary care physician (PCP) workforce to offer office-based addiction treatment with buprenorphine, as other countries have done. As of 2017, according to the Kaiser Family Foundation, there were more than 320,000 PCPs, plus a broad workforce of nurse practitioners and physician assistants, treating U.S. adults. In contrast, there are just over 3000 diplomates of the American Board of Addiction Medicine, and only 16% of 52,000 active psychiatrists had a waiver to prescribe buprenorphine in 2015 (moreover, 60% of U.S. counties have no psychiatrists).3 Training enough addiction medicine or psychiatric specialists would take years, and most methadone treatment programs are already operating at 80% of capacity or greater.4 However, PCPs and other generalists, including pediatricians, obstetrician–gynecologists, and physicians who treat human immunodeficiency virus (HIV) infection, are well situated to provide