Nirvana Recovery

The Vital Role of Primary Care Providers in Treating Opioid Use Disorder in Arizona

Role of PCP in Treating Opioid Use Disorder in Arizona

The opioid crisis has hit Arizona hard, with over 1,927 opioid overdose deaths in 2022 (with Maricopa at 26.0% and Pima at 31.2%) and 244 confirmed opioid deaths in May 2024 alone. Over 6.1 million people (aged 12 and older) had opioid use disorder (OUD) in 2022. Similarly, 2.5 million Americans (aged 18 years or older) had OUD in 2021, out of which only a mere 22% received treatment. This treatment gap is even starker in Arizona, where rural communities often lack access to addiction specialists. However, a key solution lies in empowering primary care providers (PCPs) to prescribe buprenorphine, a highly effective OUD medication. With their long-term patient relationships and proximity to underserved areas, Arizona PCPs have a vital role to play in expanding buprenorphine access and reversing the tide of the opioid epidemic.

Opioid Fatality Rate per 100000 Population by County

The Need for Mainstreaming OUD Treatment in Primary Care

The Extent of Untreated OUD

  • A 2018 study found Arizona had high prescribing rates, suggesting widespread availability of these addictive drugs.
  • Many patients with OUD go unrecognized in general medical settings.

Barriers to Accessing Specialty Addiction Care

  • 766,272 Arizonans, predominately in rural areas, live in “pharmacy deserts” with limited access to pharmacies that could dispense buprenorphine.
  • Transportation challenges further impede many Arizonans’ ability to visit faraway specialty addiction clinics frequently.

The Power of the PCP-Patient Relationship

  • Patients feel PCPs are qualified to treat addiction, and their long-term rapport allows them to motivate patients to seek help.
  • Studies show high patient satisfaction with primary care office-based buprenorphine treatment.

How Buprenorphine Works as an OUD Treatment

Buprenorphine's Unique Pharmacology

Buprenorphine MOA
  • As a partial opioid agonist, buprenorphine reduces cravings and withdrawal by partially activating opioid receptors in the brain, but has a “ceiling effect” that lowers euphoria and respiratory depression risk compared to drugs like heroin.
  • This makes buprenorphine a safer option than full agonists like methadone. Buprenorphine also has a long duration of action, allowing for alternate-day dosing.

Effectiveness of Buprenorphine Treatment

  • Buprenorphine decreased opioid use and increased treatment retention in placebo-controlled clinical trials
  • Patients who received buprenorphine are 38% less likely to die from opioid overdose than those not on medication.
  • Buprenorphine is most effective as part of a “whole-patient” approach with behavioral counseling and support services. PCPs can provide this directly or via referral.

Nuts and Bolts of Prescribing Buprenorphine

Federal Requirements for Prescribing

  • Physicians must complete an 8-hour training and NPs/PAs 24 hours of training to apply for a DEA “X-waiver” to prescribe buprenorphine. 
  • In 2021, new guidelines allowed providers to skip the training and treat up to 30 patients after submitting a Notice of Intent to SAMHSA.
  • Limits on the number of patients a practitioner may treat with buprenorphine have been removed, and SAMHSA will no longer accept Notices of Intent for X-waiver registration.

The 4 Phases of Buprenorphine Treatment

Patient Flow Through Phases Of Buprenorphine Treatment
  1. Initiation – Screen using validated tools like the DSM-5 OUD Checklist. Educate patients and obtain consent.
  2. Induction – Patients abstain from opioids for 12-24 hrs and begin buprenorphine when in moderate withdrawal. Can be done in-office or at home with telehealth guidance.
  3. Stabilization – Titrate dose over 1-2 weeks until cravings subside without side effects. Typically 8-24 mg/day.
  4. Maintenance – Continue stable dose with monthly check-ins. Frequency can decrease over time if the patient is doing well. Pair with counseling.

Logistical Considerations

  • Identify local behavioral health and social service partners for referrals.
  • Establish relationships with pharmacies experienced in dispensing buprenorphine.
  • Utilize team members like nurses to assist with initial screening and ongoing monitoring.
  • EHRs can be customized for buprenorphine treatment notes and state PDMP queries.
  • Designate time slots for OUD visits and start with a small number of patients. 
  • Arizona Medicaid (AHCCCS) and most private insurers cover buprenorphine with prior authorization.

Getting Support to Succeed with Buprenorphine

  • Join Project ECHO (Extension for Community Healthcare Outcomes), offered by ASU’s College of Health Solutions.
  • Connect with the 24/7 Opioid Assistance + Referral Line for consults on difficult cases. 
  • Connect with a Opioid Treatment Network mentor like AzMAT Mentors Program.

Conclusion

Primary care providers have an exciting opportunity to expand access to evidence-based opioid addiction treatment across Arizona dramatically. By learning to screen for OUD and prescribe buprenorphine, PCPs can help restore health and hope to countless patients and families struggling with this life-threatening disorder. While embarking on this journey takes commitment and a willingness to innovate, Arizona PCPs will find a wealth of training, tools, and support to guide them each step. The relationships PCPs foster with their patients, coupled with the scientifically proven effectiveness of buprenorphine, can be powerful weapons in the fight to end Arizona’s opioid epidemic. As the most trusted touchpoints in healthcare, primary care providers are uniquely positioned to mainstream OUD treatment and save lives in every corner of our state.

Furthermore, if you’re curious to learn more about practical tools and the screening and initiation phase, check out the pdf attached below. It has all the necessary details so you don’t miss any information. 

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Nirvana Recovery