Medication-assisted treatment (MAT) is widely considered the gold standard for treating opioid use disorder (OUD) when combined with behavioral therapies. Yet the number of primary care providers practicing MAT remains stubbornly low. Medical providers who have a waiver to prescribe buprenorphine—one of three medications approved by the Food and Drug Administration (FDA) to treat opioid use disorder—often report significant challenges to practicing MAT, from navigating inadequate reimbursement rates to overcoming the institutional stigma of treating people with substance use disorders. How can providers get around these obstacles?
To answer this question, we conducted 10 in-depth interviews with providers from the medical, social services and recovery communities in Michigan who practice or support MAT. The interviews revealed three clear steps:
Overcome institutionalized stigma and misconceptions about MAT;
Take a team approach to providing these services; and
Cultivate supportive external relationships.
These steps do not solve the structural and systemic challenges to practicing MAT, which require coordinated advocacy from patients and providers, but they shed light on a path to delivering this lifesaving care in the interim. Below are the three steps and how providers are implementing them.
Overcoming stigma, misconceptions
Institutional stigma continues to prevent many health care organizations from providing MAT. Providers we spoke with said they overcame this by championing respectful, non-stigmatizing language within their organizations. Some socialized within their medical practice the DSM-5's language guidelines or guidance from other sources, such as the consumer-led health advocacy organization Community Catalyst. The latter stresses the importance of replacing terms such as “recreational user” with “person starting to use drugs,” and “drug abuser” with “patient living with a substance use disorder,” for example.
Some of the providers recommended checking all patient communication materials, such as posters and brochures, to ensure language is respectful. Research shows that using respectful language helps end stigma, and also leads to better quality of care. It’s also central to establishing trust with patients.
Others emphasized the importance of talking openly with peers and colleagues to share what is involved in MAT. They said many providers mistakenly believe MAT is difficult to administer when, in fact, it is easier than managing a patient with diabetes on insulin. Some physicians are hesitant to treat justice-involved or previously incarcerated individuals, and few are aware of the professional satisfaction that can come from helping someone turn his/her life around, said the providers in our study.
Building a strong care team
Providers emphasized that MAT services are most successful when built around a team of specialists who hold routine team meetings to share best practices, encourage excellent care and refine the clinical process as needed. The care team will vary in size and capability depending on the practice, but may include not only the DEA-waivered medical provider but also a licensed professional counselor, and a medical assistant who processes paperwork, greets the patient and schedules appointments.
MAT is still a relatively unfamiliar approach for many providers and their patients, which makes it more important for all involved to understand the treatment and possible outcomes. For instance, a patient may need MAT for up to a year before seeing a positive change in day-to-day life. Making sure the care team knows the process and carries it out consistently ensures better outcomes, providers reported.
Some providers give a welcome packet to new patients and their families with information about what to expect. Providers have managed expectations among their staff by creating a formal written process for clinical staff where roles and responsibilities throughout the treatment period are clearly defined and reinforced in daily practice.
Cultivating supportive external relationships
Providers we spoke with felt they received little support at the federal and state levels for providing a service that is critical to addressing a public health crisis. In response, many have created informal support structures, such as networking groups of providers delivering MAT who share practices and ideas to enhance their care and address challenging cases. They formed these connections by tapping into their professional networks, such as their state primary care association.
They also cultivated relationships with other local health care providers, such as cognitive-behavioral therapists, to provide referrals and help their patients stay successfully engaged in MAT services. Many built relationships with other local health providers and pharmacists to get around delays in obtaining prior authorization for the first prescription, which is needed quickly to keep the patient on a path to recovery.
Do these steps remove all barriers to physicians practicing MAT? Unfortunately, they do not. Providers in our study urge their peers to lobby state and federal legislators to address the structural and regulatory issues that they believe prevent so many doctors from practicing MAT, such as confusing reimbursement codes, inadequate reimbursements and large numbers of people with an opioid use disorder who can't afford care. They recommend being vocal on these high-priority issues by serving on advisory boards, submitting public comments and writing letters to elected officials.
These structural reforms won’t happen immediately, but it’s reassuring to see that many doctors are still finding a path to practice MAT in their communities, despite the challenges.
Lena Marceno, MSc, is a program manager in the Center for Behavioral Health at the nonprofit research and consulting organization Altarum, and lead author of the research brief Medication-Assisted Treatment and Recovery Best Practice Guide.