As President of the American Board of Addiction Medicine, Dr. Patrick Gerard O’Connor is a national expert on medication-assisted therapy and evidence-based practices. As the Section Chief of General Medicine at the Yale Medical School of Medicine, Dr. O’Connor has focused his scholarly work on the interface between primary care and substance abuse. His publications include studies on the management of opioid withdrawal in primary care settings, opioid maintenance in primary care, and the use of Naltrexone for treating alcohol dependence in primary care patients. Dr. O’Connor recently co-chaired a national symposium with Recovery Czar Michael Botticelli entitled, “Medicine Responds to Addiction” at the White House.
Addiction medicine is opening the door by allowing physicians from any field and not just psychiatry to specialize in addiction.
At the start of your medical career, you received SBIRT training. SBIRT is an acronym for Screening Brief Intervention & Referral to Treatment. Can you describe this training? Do all doctors receive it? If not, should all doctors be required to have SBIRT Training today?
Before I came to Yale, I did SBIRT training during my residency, and I have been involved in SBIRT training during my time at Yale. SBIRT training is an acronym for Screening Brief Intervention & Referral to Treatment. SBIRT is a comprehensive public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders.
We emphasize the importance of SBIRT training here at Yale, and we have had that training program in place for a number of years. The training program has been done in collaboration with colleagues in other departments. For example, we have worked very closely with the Emergency Medicine Department. We have tried to also provide training in SBIRT for some of the major residency programs like internal medicine, pediatrics, OBGYN and emergency medicine as I just mentioned. The idea is to try to get all residents and medical students to have this training.
The training itself involves a variety of curricular pieces, including case studies, training videos, slide sets for the faculty to use, along with training manuals and modules for SBIRT. We have a basic presentation that gives the nuts and bolts of SBIRT. Then we have a series of activities where the residents try to learn and practice SBIRT techniques so they hopefully can later apply it to their clinical settings.
In regards to your question of whether all doctors receive this training, unfortunately, the answer is no. There are a lot of institutions across the country where SBIRT training is not available. In fact, it’s certainly more the case that it’s not available than it is available. From my perspective, all doctors should have SBIRT training as part of their basic learning procedures, both in medical school and in residency programs. It’s a very straightforward skill that builds upon the foundational interviewing techniques that physicians learn to provide for a whole variety of conditions that their patients have. Why not use those same type of skills and apply them in their care of patients with substance abuse disorders?
SBIRT training involves basic skills around raising a subject with a patient, providing feedback about alcohol and drug use, trying to come up with strategies to help enhance the motivation to change when people are ready to change, then coming up with a plan. Not coming up with a plan on their own, but assisting people in the process of coming up with a plan that will help them make that change. It’s pretty darn important stuff, and it should be available much more than it is now.
You are the current president of the American Board of Addiction Medicine (ABAM). Can you tell us about ABAM, and what it has been able to accomplish?
Certainly. The American Board of Addiction Medicine was created back in 2007 to help certify and maintain the certifications of physicians in the field of addiction medicine. What we are trying to do through this process is to assure that high quality addiction care is accessible to everybody. ABAM is what we are currently calling an independent board and that means a board that is not part of the much larger American Board of Medical Specialties (ABMS). One of the primary goals of the organization is to move addiction medicine from being an independent specialty to being part of ABMS. We think that we are pretty close to doing that now. We have certified over 3,000 physicians in the field. We expect to see those numbers continuing to grow as we move forward.
It’s important to note that ABAM is overseen by a board of directors, and those directors are professionals that represent eight different medical specialties. We are really trying to bring addiction medicine to all of medicine. The specialties on the board include psychiatry, internal medicine, OBGYN, family medicine, emergency medicine, pediatrics, preventive medicine, and surgery. The makeup of our board really makes the point that we view addiction medicine as a multi-specialty field. Physicians from all kinds of backgrounds are needed and can participate as addiction medicine specialists.
Another big part behind the question of why the American Board of Addiction Medicine has come into being is to support the development of training programs in the field. Just like we had zero diplomats back in 2007 to represent addiction medicine, we also had zero fellowship programs. Now we are up to 37 of those programs in major medical centers throughout the country. We anticipate that number is going to continue to grow over the next several years. The goal is to have an addiction medicine program at every major medical school in the country in the not-too-distant future. We are well on our way toward achieving that goal.
For many patients, abstinence represents an ideal to be recommended, but the harm reduction approach can help as well.
Do you believe the Affordable Care Act has changed the landscape of addiction medicine and the treatment industry in the United States? Are these changes for the better?
I would say that certainly the letter and spirit of the Affordable Care Act in terms of putting in basic insurance reforms to ensure that everyone has access to affordable healthcare, including healthcare-related substance abuse and substance abuse disorders is changing the landscape. No doubt that’s what the Affordable Care Act put into place as part of its mandate. I think we are just beginning to see that happen in very positive ways, but we still have a ways to go. The entire healthcare field has to get reoriented to seeing substance use and substance abuse disorders the same way that they see other diseases and illnesses and problems that people present with.
Historically, as you know, there’s been a real problem in that regard from everyone’s perspective, including physicians, nurses, and the healthcare field in general as a whole. But the problem goes beyond the healthcare field to include employers, insurance companies, families and beyond. I think the Affordable Care Act is going to help shift that perspective. Although these changes are just beginning to occur, there’s no doubt that they are for the better. Still, there’s a lot of growth that needs to happen, but I believe that I am seeing the start of what will have a truly positive impact on our overall healthcare system.
You recently co-chaired a White House Symposium on “Medicine Responds To Addiction” with Recovery Czar Michael Botticelli. At the symposium, you stated, “Today, we are at a critical turning point when it comes to addiction prevention, treatment, and recovery… There is now an extensive body of science concerning the epidemiology of addiction, the consequences of risky substance use and substance-use disorders, and the effective approaches to prevention and treatment. The time has now come to advance patient care by fully integrating this science into medical practice.”
How can the science be integrated into the medical practice? If more education is needed for physicians, how should this education be delivered? Beyond changing medical school curriculums, how can doctors already in long-term practice be included?
These are all great and important questions. There’s no doubt that we have the evidence and we have the science behind addiction medicine. A lot of us have been concerned that the uptake of that knowledge into general medical practice has been slower than it should be. In terms of how the science can be integrated into medical practice, it needs to be integrated at every touch point in terms of how we deliver care to patients.
For example, medical schools have really been behind the eight ball on this issue. They simply have not given addiction-related training and information that same space in their curriculums as the traditional emphasis that the management of other diseases and conditions have received. I can’t tell you how much time I spent in medical school, like students currently spend in medical school, studying cardiology for example. There’s no doubt that cardiology is important. But you could argue that the health problem of addiction is just as important, yet it gets short shrift in terms of how it’s taught to our youngest trainees. From day one integrated all the way through the curriculum until graduation, there needs to be training about addiction medicine for all of our medical students.
Of course, such training in addiction medicine needs to continue once people go on to residency as well, and not just in the primary care disciplines. It needs to be done in all disciplines. For example, how many cases of trauma on a surgical service are related to problems of alcohol and drug use? Too numerous to count. Yet, when patients are treated in those settings, their bones might be put back together, but more often than not, no effort is made to do something specific about what caused those bones to be broken in the first place. Every specialist and every specialty need to take ownership of this issue.
With a number of specialties, we now have certification and the maintenance of certification in addiction. One of the very promising discussions we had at the White House summit was with the diverse number of specialty boards represented that expressed a commitment to integrating content about addiction medicine into their certifications and recertification exams. If physicians know that they will be tested on these topics when they take their exams, it clearly will help motivate a sufficient emphasis on addiction-oriented topics and the learning of this information. This will impact doctors in long-term practice. They are going to need to participate in that process in order to maintain their board certification.
In an interview in 2013, you pointed out how there is a profound lack of addiction medicine specialists. Has this changed over the past two years? When you discuss the need for specialists, you highlight the importance of addiction psychiatry. Why is addiction psychiatry so important, and what are the key elements of addiction psychiatry training that need to be bolstered?
In the past two years, we have seen growth in trained addiction medicine specialists from the high-two thousands to the mid-three thousands. It is moving in the right direction. It’s important to realize that addiction medicine is a field that was conceptualized as far back as the early 1700s when Benjamin Rush talked about the disease concept of alcoholism. It was the first time someone described a form of addiction as a disease. Moving forward, in this century in our country, the American Academy of Addiction Psychiatry came into being.
The good news is that there are some medication options for treating alcohol dependence and alcohol problems. Unfortunately, like other therapies we talked about earlier, they tend to be underused.
Psychiatrists were the first group of physicians to develop an addiction specialty within their field. In 1991, addiction psychiatry was first recognized as a formal specialty. Currently, there about 46 accredited addiction psychiatry programs and a little over 1,000 certified diplomats in addiction psychiatry. Within medicine, addiction psychiatry got onboard first. It’s important to note that addiction psychiatry is a field limited, of course, to psychiatrists. To become an addiction psychiatrist, you have to first become a psychiatrist, then do a fellowship program in addiction psychiatry to get the certification. But it’s incredibly important to mark what psychiatry did by creating this discipline because it was the start of the formal field of addiction specialists. Addiction medicine is opening the door by allowing physicians from any field, and not just psychiatry, to specialize in addiction and become certified as an addiction specialist physician. By opening addiction medicine up to physicians in all fields, we hope it will greatly increase the number of physicians specializing in addiction.
Do you believe Suboxone and other form of Medication-Assisted Treatment (MAT) are changing the face of addiction medicine in the United States? Given the extent of the national opioid epidemic in the forms of prescription painkillers, heroin and even fentanyl patches, is the treatment industry embracing these evidence-based treatment options fast enough?
To address the first part of the question, I believe Suboxone and other types of addiction medication have absolutely changed the face of addiction medicine in the United States. You can compare it to the development of methadone in the 1960s. You fast forward to the 2000s and methadone remains the one and only medication-assisted treatment option, literally the gold standard of medication-based treatment for opioid dependence. Since then, the introduction of buprenorphine, known by the brand name Suboxone to most people, and its approval by the FDA in 2002. Now there are more people treated with Suboxone for opioid dependence than are treated with methadone so there’s no doubt that Suboxone has had a profound effect.
It’s not just because the number of patients that now receive highly effective medication-assisted therapy, but it’s also where they receive it. As effective as it is, methadone is only available in highly regulated methadone maintenance programs. Methadone maintenance programs are not necessarily available in every community or even available in every region of the country. Suboxone, which can be prescribed by appropriately trained generalist physicians, has greatly improved the availability of and access to medication-assisted therapy. This is not just because of the greatly expanded number of places where you can get such therapy. It’s also because of a shift in the spirit by which that therapy is received.
Unfortunately, my experience has been that there are a lot of individuals who are dependent on opioids who just refuse to go to methadone maintenance programs. They associate stigma with them. They associate other negative feelings with these programs that are really misplaced in light of the need to treat opioid dependence. For whatever reason, they won’t present to methadone treatment programs, but they will go see a primary care physician who can provide the new treatments. As a result, it has really opened a lot of doors that haven’t been opened in the past.
The question to ask is whether there is enough treatment available today. No, there’s not. We need to continue to expand the availability of this kind of treatment. Of course, such expansion must come with an effort towards making sure that such treatment is high quality. We don’t want to just hand out medications willy-nilly. If it’s going to be evidence-based, we have to make sure that it’s done right.
You are a major proponent of the importance of using urine toxicology to test patients for drugs of abuse. In a sense, without such tests, aren’t we asking a physician to read a book blindfolded when it comes to choosing treatment options? Given the inexpensive nature of drug testing today, isn’t knowing more always better?
Yes, I am a proponent of using drug testing for patients. Of course, like any test that we use in healthcare settings, it needs to be applied intelligently and thoughtfully. It also needs to be applied in partnership with patients in a patient-centered manner. Urine toxicology testing is only one piece of data we collect when assessing patients. There is a lot of other data that we collect as well. In the context of the big picture of assessing folks with potential substance use disorders, my feeling is that, if done the right way, urine toxicology testing can be very, very valuable.
Whenever I use it, I always have to be certain I understand the methodology that the test is using, what the test can do and what it can’t do, and I always involve patients in the discussion. Urine toxicology testing for substance use disorder is underused and should be more widespread. But I need to emphasize again, it needs to be used intelligently, thoughtfully, and in a patient-centered manner where the patients are involved in the discussion from the beginning.
When it comes to primary care patients in America and their drinking patterns, do you consider drinking to be a main cause of health problems in this country? Would removing alcohol use, abuse and dependence have a dramatic effect for the better?
There’s no doubt that alcohol use is a primary cause of all kinds of health problems. It’s well-known that it’s a cause of liver disease and cirrhosis. We know it to be a cause of cardiovascular disease and of high blood pressure. We also know it can be related to important cancers. In fact, I think of alcohol as the one drug that people use that can affect every organ of the body; the nervous system, the cardiovascular system, the digestive system. Every part of the body can have negative impacts from alcohol. It’s a huge primary cause of health problems and this is without a doubt.
Of course, we also know that alcohol causes problems that do not relate directly to specific organ systems. For example, trauma: People drink too much and they get in car accidents, they get in fights, and they misuse firearms. All kinds of things can happen under the influence of alcohol that can cause trauma. We also know it’s related to disturbing events in people’s daily lives such as domestic abuse and acts of violence. And this really highlights the issue of why we need to train doctors at every level in this area.
If the second part of your question means would we be healthier if people stopped drinking, the answer is absolutely. It would have a profound and dramatic effect on the healthcare of our country if people stopped using alcohol. No doubt about it.
In research published in 2005, you helped to develop the Brief Negotiation Interview (BNI) to address a population of HH (“Hazardous & Harmful”) drinkers often seen in emergency rooms. Can you describe this interview process? Has it been implemented in many hospital settings?
This was a specific SBIRT (Screening Brief Intervention & Referral to Treatment) approach called the Brief Negotiation Interview (BNI), and it’s based on the principles of SBIRT. It was developed specifically for use in emergency rooms. With the BNI approach, we developed something that could be used by the providers themselves, by the physicians and other providers that work in the emergency room, in the routine care of their patients. The BNI was about the development of tools that people with their boots on the ground in the emergency room could use in the process of caring for their patients.
Using the Yale Emergency Department, we did studies to develop this process. The BNI has five basic steps. The first step is to screen all patients, using whatever screening instrument one wants to use, to identify people who may have hazardous drinking as part of their life story. The second step is to raise the subject. I might say, “Hi, I’m Dr. O’Connor. Would you mind taking a few minutes to talk with me about your alcohol or drug use.” It’s basically a step to let the patient know that you’ve identified an issue that an important part of their healthcare, and you want to talk to them about it. My experience is that if you tell patients you want to talk to them about something, they will talk to you. Step two is an essential part of the BNI.
Step three is providing feedback. What that step involves is reviewing the screening information that you collected from the patient that indicated to you as a physician that you have identified a problem. You might say something to the patient like: “I understand from the screening that you are drinking this much. We know that drinking above certain levels can cause problems. This is why I am concerned about your drinking and drug use. Let’s review the screen and the information together.
A goal of this review is to try to make a connection between that information and what is going on with their health. It can be as direct as, “Do you see a connection between this drinking behavior that I’ve described and the reason for your visit to the emergency room?” Maybe they came in for a car accident, maybe they came in with a cardiac problem. For step three to be effective, did they come in with a problem or a symptom that you can relate directly to their drinking or drug use, or, in the process of interviewing them, did you find other health-related problems that can help you make that connection. Next you can be very explicit with them. With drinking, for example, we show them in writing what the federal guidelines and norms are for drinking behaviors. That’s providing feedback.
The fourth step is really trying to enhance motivation. The goal is to help motivate them to do something different. The enhancing motivation step involves both assessing how ready they are to change their behavior, then trying to use that assessment of their readiness to help them gain interest in doing something about that behavior. Once you identify that the patient is maybe willing to do something, then you can move on to the fifth step. The fifth step is called negotiate and advise where you come up with a drinking goal for the patient. In some cases, it might be reducing their alcohol use to what is considered through those federal guidelines to be safe use. In other cases, it might be recommending not using alcohol at all. It depends on the patient and the specific situation. After negotiating, we try to put something into writing that summarizes the agreement that we have come to.
That’s what the BNI is: screening, raising the subject, providing feedback, enhancing motivation, then negotiating and giving specific advice around drinking behaviors. Our experience is the BNI is very doable in the process of routine care in the emergency room. We also think it’s very doable in primary care and in other settings as well. We are hoping that based on our research, the BNI is being implemented in more and more hospital settings. Like anything else that’s new, however, it takes time for it to be taken up, so stay tuned. Let’s see what the future brings on that one.
Given the effects of both alcohol and drug abuse and dependence on so many primary care patients, do you believe physicians should be performing more interventions? Is performing such interventions a fulfillment of their Hippocratic Oath?
Yes and absolutely. The Hippocratic Oath is really an important approach to how physicians and patients interact. Inherent to the Hippocratic Oath is that physicians will respect and understand the scientific gains of our field and will apply that science to the benefit of the sick and will do this all for the betterment of their health and the betterment of their well-being. In this interview, we have talked about two of the interventions that can be used, the SBIRT and the BNI, and we have also talked about medication-assisted therapy. Both of these are approaches that primary care physicians are more than capable of doing. Training is available, and we have seen an uptake, particularly of the medication-assisted therapy, over time, but the uptake has to be greater than it has been. I do believe very strongly that physicians should be performing many more such interventions.
What are the most effective FDA-approved medications for preventing alcohol abuse and dependence that help lead a patient to a path of recovery and sustainable sobriety?
The good news is that there are some medication options for treating alcohol dependence and alcohol problems. Unfortunately, like other therapies we talked about earlier, they tend to be underused. They should be used more than they are.
For many years, we only had one such therapy available, which was disulfiram, more popularly known as Antabuse. Antabuse can be effective for some patients, but far from all. It was the only alcohol dependence medication available for a number of years. There weren’t any other options available until 1994 when the FDA approved Naltrexone for relapse prevention in alcohol dependence. An important thing to know about Naltrexone is that it was only available in pill form back in 1994. In 2006, an injectable formulation was developed. Rather than having to take a pill every day, you could just get an injection once a month. In 2004, the FDA approved acamprosate. Acamprosate, sold under the brand name Campral, was formulated to help stabilize the chemical balance in the brain that would otherwise be disrupted by alcohol withdrawal.
Overall, these drugs are moderately effective at helping people who have stopped using alcohol. All of these drugs, Naltrexone in particular, are believed to reduce a alcohol dependent person’s craving for alcohol. In other words, they decrease the desire to consume alcohol in those who are alcohol dependent. It is surprising to me how little uptake these medications have had by the medical community broadly, and I think they are underutilized. They should be used more, and primary care physicians can use both Naltrexone and acamprosate. You don’t need to be a specialist to use those medications. You need to know how to use them, but non-specialists can use them as well.
These medications are not silver bullets, they are not cures, but they can be a helpful component of therapy to help people find a path to recovery and a sustainable sobriety. They are a tool in our toolbox, but they are underutilized. They should be included in a program of recovery that includes counseling and other forms of support.
Do you believe that sobriety in the form of complete abstinence is a requirement for overcoming alcohol abuse and dependence? Given the genetic origins of alcoholism, is recovery an all-or-nothing affair as believed by the 12-step programs?
This is a really interesting question for which you’ll find lots of different answers. I’ll give you my answer. When you look at this question of complete abstinence and what role should abstinence play, I think you need to look at individual patients to make that determination. I just don’t think there is a blanket statement that you can make that applies to all patients.
By and large, abstinence is the ideal goal when it comes to patients with alcohol abuse and dependence. It is the goal that should be front and center. Does that mean that people who can’t maintain complete abstinence shouldn’t be provided continued care and support? No. For some people, a harm reduction approach where they can’t quite get to complete abstinence, but they can reduce their use and hopefully therefore reduce their risk of complications makes sense. It’s something that not only should be supported, but also built upon to help them achieve complete abstinence down the road.
Is recovery an all-or-nothing affair? I don’t think that’s necessarily the case. For many patients, abstinence represents an ideal to be recommended, but the harm reduction approach can help as well. It’s important not to throw the baby out with the bath water. With many patients, a goal short of abstinence can have a very positive effect on their health.
John Lavitt is the Treatment Professional News Editor at The Fix. He last interviewed President Obama’s “Recovery Czar” Michael Botticelli.