Bob Levy, M.D., and his colleagues at Broadway Family Medicine Clinic in Minneapolis believe that opioid use disorder (OUD) should be treated like the chronic illness it is. With medications like buprenorphine, or suboxone, readily available, Levy argues that people struggling to break their addiction to opioids can be seen in their regular physician’s office, alongside patients with other common chronic illnesses like diabetes, heart disease or asthma.
The attitude that all people with OUD must be separated from the general public and cared for in addiction centers is antiquated, Levy said: In most cases, opioid addiction can be treated by the same doctor who prescribes your blood-pressure medicine or your prenatal vitamins.
“Most people with OUD don’t need to see an addiction medicine specialist,” Levy said.
In Levy’s experience, traditional addiction treatment without medications often doesn’t work for people with OUD — and the results can be fatal.
“It’s hard to watch young people die of overdoses over and over again,” he said. “As a physician it gets you horribly sad and angry. I still remember my first patient who died of an overdose. It was awful, horribly sad. There are better things we can do.”
So Levy decided to try a different approach.
A primary care doctor specializing in addiction medicine, Levy completed a fellowship in addiction and chronic pain at Hazelden Betty Ford before joining the faculty of the University of Minnesota North Memorial Family Medicine residency in 2012. He oversees residents and treats patients at Broadway Family Medicine, a comprehensive clinic that offers a residency program through the University of Minnesota and North Memorial Health Hospital.
Dr. Bob Levy“I came from primary care,” Levy said. “My heart belongs in primary care, despite my specialty training. I believe that OUD treatment belongs in primary care just like diabetes treatment does. Ninety percent of diabetics are treated in primary care. Ninety percent of people with OUD should be treated in primary care, too.”
Not long after Levy arrived at Broadway, he began prescribing buprenorphine to treat his patients with OUD. He’d seen patients respond well to this therapy at Hazelden Betty Ford, and he believed that wrapping this service into regular care services offered at the clinic would help reduce shame and discrimination around OUD and maybe even encourage more people to get the help they needed.
“What I envisioned is treating addiction similarly to the way I treat other chronic illnesses,” Levy said. “Addiction is a chronic illness, after all. That’s the model we’re working on here.” In 2012, Levy began prescribing buprenorphine to a small number of Broadway patients with OUD, carefully monitoring their progress on the treatment.
Kacey Justesen, M.D., program director of the University of Minnesota North Memorial Family Medicine Residency Program, recalled that as soon as Levy began demonstrating success with this approach, interest picked up at the clinic.
“Our residents pretty quickly became intrigued,” Justesen said. “They wanted to get involved. What happened over subsequent years is it really snowballed.” As they saw how Levy’s approach to treating OUD worked with patients, “More and more residents wanted to get involved and more faculty wanted to get involved as well.”
While this approach to treating OUD alongside other chronic illnesses in a family medicine clinic is still considered “novel,” Justesen said, seven years later, “all of our faculty physicians are doing medication-assisted treatment (MAT) with buprenorphine, and all of our licensed residents are in the process of getting the waiver that’s needed to prescribe it to patients.”
Faculty and residents got on board with Levy’s approach, Justesen said, because they understand that this may be a way to help lessen the larger societal impact of addiction. And since the Broadway program trains residents who will one day go on to work in family medicine practices around the state and the nation, the hope is that this approach will spread.
The benefit of this training is largely felt at home. In acknowledgement of this fact, the Minnesota Department of Human Services awarded Broadway Family Medicine $400,000 to support its work to train medical residents to provide MAT by helping the clinic expand its behavioral health services.
Dr. Kacey JustesenAfter completing their residency, “70 percent of our residents stay in Minnesota,” Justesen said. “Some are staying in the metro area and some are going to rural areas.” With this focus on MAT for OUD in their residency program, she added, “We are dramatically increasing the providers (eight to 10 graduates each year) in the state that are able to provide buprenorphine to their patients through this program.”
And it’s about even more than the sheer number of new physicians that the program turns out each year, Levy added. Broadway’s special sauce is the unique “chronic illness” approach to treating patients with SUD that its faculty models for residents.
“The most special thing about our program is that we are constantly training new family medicine physicians to do addiction treatment with medication in a clinic-based approach,” Levy said. “This approach is still lacking these days, but we are showing more new doctors how it really can work. Hopefully the numbers will pick up.”
Perhaps what makes Broadway Family Medicine different from other programs that offer MAT for patients with OUD is the sheer ordinariness of the place.
Though some people might assume that a facility known to offer treatment for patients struggling with opioid addiction might be a little rough around the edges, “We look and feel like a regular health clinic,” Justesen said. Doctors in the practice help many patients fight opioid addiction with buprenorphine, but they also see patients for other health issues, from diabetes to pregnancy to arthritis or influenza. Everyone is mixed together.
“Honestly I don’t think other patients within the clinic really know what we’re doing (with OUD),” Justesen said. “Visits are very private and confidential. There is no way any person in the lobby would know what the person next to them is coming to the doctor for.”
And there really isn’t much that sets OUD patients apart, Levy said. Most of the time, suboxone treatment is, he explained, “like going to your doctor for your diabetes checkup. It is a lot of bread-and-butter primary care stuff.”
Levy said that he and his colleagues want OUD treatment to be “fully integrated into our primary care clinic. It is not at a special site or with a special doctor. Everybody does this. That’s the whole point.”
When everyone has a hand in treating patients with opioid addiction, the disorder loses its sense of shame or secrecy, Justesen explained.
“Over the past few years, there has been a real stigma around patients with OUD,” she said. “We find that breaking that stigma down and accepting everybody coming through our door to get the help they need is the absolute best approach. We are welcoming everyone, congratulating people for coming to us and asking for help. That is such a big step.”
Thanks in part to the DHS grant, the clinic offers a comprehensive set of services for patients facing addiction. Program staff includes a care coordinator, a psychologist and a licensed alcohol and drug counselor (LADC).
“There are other clinics that are doing OUD treatment,” Justesen said. “Our approach, of treating it in a family medicine clinic and having comprehensive services available, is unique, and we’ve been fortunate to be able to build it up over the years. It is integrated well into our clinic.”
From Justesen’s perspective, a family medicine clinic is the perfect place to treat patients for opioid addiction.
“In family medicine, chronic disease is what we do,” she said. “We’re specialists in treating a variety of chronic diseases.” When physicians consider OUD to be a run-of-the-mill chronic disease, not a shameful disease that needs to be hidden from sight, she said, patients respond positively: “We are providing a safe, nonjudgmental environment for people to come and seek treatment not only for their OUD but also for their other primary care needs.”
How suboxone treatment works
A third-year resident at Broadway Family Medicine, Anne Doering, M.D., sees patients for a range of illnesses. Mixed in with people seeking help for asthma or anxiety is a group of patients with OUD who see her regularly for maintenance of their suboxone, or buprenorphine, treatment. These patients have an addiction to opioids and the drug, with careful monitoring by a physician, helps them reduce or eliminate their cravings.
Doering has been prescribing suboxone for a year. Seeing patients for suboxone treatment “is a normal part of my day now,” she said. “It would be unusual for me to not see patients for suboxone as much as I see them for their prenatal care or high blood pressure.”
For many patients and their physicians, the goal in suboxone treatment is to eventually spread out the number of doses required to keep cravings at bay. To achieve this, patients and doctors work closely together to determine the ideal dose of the drug required and then to maintain or even decrease that dosing over time.
“I have 10 patients who are well maintained and they come in every month approximately for their suboxone,” Doering said. For most patients, it takes time and hard work to get to this point of even regularity.
One of Doering’s regular patients is a good example.
Dr. Anne Doering“She was not doing all that well at first,” Doering said. “She was using multiple substances as well as her suboxone. Eventually she went into court-ordered treatment and did very well. She is now seeing me every month for her suboxone treatment and she is doing fantastic.”
When Doering first meets with a patient with OUD, she determines if she thinks suboxone treatment is right for them. Some people do better on more traditional, highly monitored medications like methadone, but many can find relief from their symptoms when their suboxone dosing is well monitored.
Doering consults closely with her patients at the first appointment. They talk about the risks and benefits of different OUD treatment options. “If we determine suboxone is a good option for them, I would prescribe it and then see them back within a week,” she said. “We’d see them weekly for a time, or if they are doing good we would space out the visits from every week to every two weeks to eventually once a month.”
Suboxone is manufactured in multiple formulations, Doering explained: “It is available as a dissolvable film or a tablet that you can take under the tongue. You take it at least once a day.” Depending on cravings, “some people take it twice a day. I can prescribe a month’s supply. Then the patient goes to their pharmacy and fills it.”
Suboxone can now also be administered as a monthly injection delivered in a doctor’s office. “This form is really new,” Doering said. “It can be easier to use for some patients. You don’t have to remember to take it every day. It wouldn’t be something that was administered to a patient against their will, but it can make taking the medication easier to manage.”
‘Relapse is part of the disease’
Not every patient is able to spread their suboxone dosing out to once-monthly appointments with their physician, Doering said. And sometimes patients relapse from treatment and start using opioids again. This is something that she and her colleagues at Broadway consider to be part of the disease process.
“One of the things I often say to patients when it comes to relapse is unfortunately relapse is part of the disease,” Justesen said. “I wouldn’t stop seeing a patient with diabetes if their glucose control got out of whack. I would try again to treat their diabetes with another approach. We would make some changes and work toward getting things under control. We approach OUD the same way.” The clinic sometimes refers patients to addiction-treatment programs. After completing treatment, the patient returns to the clinic for suboxone continued treatment.
Doering said that her goal is not to eventually wean OUD patients off suboxone. It is to find the treatment level that works for them, and to monitor their progress.
“It’s the same thing I would do for someone who is closely monitoring their blood pressure,” Doering said. “It becomes something you check in with once a week or once a month or ideally every three months. We move toward treating it like a well-managed chronic disease.”
Most people with OUD will continue to take suboxone for years, Doering said. She does not see this as replacing one addiction with another.
“Medicine is all about what is the risk and the benefit and how can we most improve outcomes for patients,” she said. The benefit of buprenorphine treatment is that it gives people with OUD their lives back. “Patients want to stay alive and they want to be able to live their lives. This medication allows them to do that.”
Doering said that it’s been her experience that expecting people with OUD to quit cold turkey often fails. “If we say, ‘Just get it together and stop using,’ that doesn’t work,” she said. “People die from that. Certainly there are people who choose to approach it that way and there are treatment organizations that teach that approach to sobriety, but that doesn’t work for most people.”
There are some treatment organizations that encourage clients to work toward a goal of complete abstinence, but Doering doesn’t think that is realistic.
“There are patients who, after a period of time, are able to taper off suboxone,” she said. “It is not something we encourage, because in those cases the rate of relapse is higher. There are no adverse effects from long-term suboxone use.”
This attitude fits well within the chronic-illness approach to treating OUD. A physician wouldn’t encourage a patient with diabetes to stop taking insulin if insulin were keeping him alive. Doering firmly believes that suboxone keeps some of her patients alive. And in her experience, suboxone use also keeps patients out of the ER or urgent care, further reducing the cost to society.
“When we look at outcomes in general for situations where we expect people to stop using completely, their risk of relapse is significantly higher when they are not on an opioid treatment program with a medication like suboxone,” Doering said. “When people relapse they die. If we find a medication that works and allows people to live their lives rather than risk death, this is something we should be focusing on.”