Psychiatry’s Role in the Opioid Crisis: What Should It Be?

The opioid public health crisis continues to make headlines but contrary to prevalent thinking, it’s not new. From 1999 to 2017, almost 400,000 people died from opioid overdoses, say the Centers for Disease Control and Prevention, which rightfully call the current situation an “epidemic.” Each day in America, 130 Americans die from an opioid overdose, and the surgeon general has reported that only about 1 in 10 people with a substance use disorder receive any type of specialty treatment.

As society cries “help,” healthcare professionals evaluate ways to stem the relentless opioid tide. Some naturally ask what role psychiatrists play in all of this.

“Psychiatry certainly sees a lot of people with opioid disorders,” says Joe Parks, MD, and medical director for the National Council for Behavioral Health. “Because there are so few psychiatrists, they’re not the major providers doing treatment for the disorders—more general medical doctors are doing that, although an increasing number of psychiatrists are specializing in addiction treatment.”

In fact, the American Academy of Addiction Psychiatry (AAAP) cites recent reports that indicate the average primary care provider has more than 2,000 patients and as many as 200 of them could have a substance use disorder.

Srinivas B. Muvvala, MD, is an assistant professor of psychiatry at Yale School of Medicine and director of the Substance Abuse Treatment Unit at Connecticut Mental Health Center. In addition to those trained in psychiatry, he wants all physicians, medical students, and residents to be trained to treat addiction, to evaluate and screen, and to provide treatment for opioid disorders.

More Training Definitely Needed

In an opinion published in JAMA Psychiatry in late November 2018, Dr. Muvvala and two co-authors say that “psychiatrists are uniquely skilled and ideally suited to be leaders in treating this epidemic” and that they “can and should be part of the solution.”

The authors say that 1,100 board-certified addiction psychiatrists aren’t enough to meet treatment needs and they want psychiatrists to “be determined to expand access to medication-assisted treatments.”

Speaking to Health eCareers, Dr. Muvvala said psychiatrists understand the neurobiology of addiction, as well as the psychological principles underlying addictive behavior.

“Additional training is sometimes needed to instill confidence, however,” he says, and in many cases, it’s sorely lacking so why not start at the earliest opportunity. “One suggestion is to ensure that all psychiatry graduates from residency programs be trained to provide treatments for opioid use disorders.”

Like some of his peers, he’d like to see at least two months—up from the current one month—full time, spent on addiction treatment that encompasses all addictions including alcohol and tobacco.

Medical Students Drive Change

“Psychiatry residency programs have done a better job than most other medical specialties in terms of training the workforce, but “there’s a long way to go,” says John Renner, MD, professor of psychiatry at Boston University School of Medicine, associate chief of psychiatry for the VA Boston Healthcare System, and immediate past-president of the AAAP. He, too, thinks psychiatrists have a potentially major role to play in responding to the opioid epidemic.

He also wants every psychiatry residency program to have a strong rotation in addiction, so graduates “are very comfortable dealing with complex patients.” They will then have the knowledge of how to use powerful and effective treatments: methadone, buprenorphine, and extended-release naltrexone—with the latter two able to be prescribed in a psychiatrist’s office.

The treatment landscape is also constantly evolving, he says, and healthcare professionals must keep pace. Synthetic opioids, mainly fentanyl, are now the most common drug involved in overdose deaths since 2016.

As Sarah Wakeman, MD, and Michael Barnett, MD wrote in The New England Journal of Medicine in mid-2018, although access to office-based addiction treatment has increased since federal approval of buprenorphine, annual growth in buprenorphine distribution has slowed instead of increasing. “To have any hope of stemming the overdose tide, we have to make it easier to obtain buprenorphine than to get heroin and fentanyl.”

“There’s change going on in a lot of medical schools around the country, with lots of interest on the part of medical students who have driven change themselves,” Dr. Renner says.

As with any curriculum change in academia, for coursework to be added, something has to go, and that’s not easily accomplished at any institution, he says. “It’s a very competitive process and stigma gets in the way.”

Co-occurring Disorders a Major Factor

In April 2018, Lama Bazzi, MD, and Elie Aoun, MD, wrote about “urgency” in Psychiatric News, as a prelude to the American Psychiatric Association’s annual meeting.

“We want to encourage psychiatrists to view substance use disorders as primary psychiatric illnesses,” they said. “For patients to successfully gain control over their addictions the same way they gain control over their bipolar disorder, we must guide them using evidence-based, patient-centered approaches.”

“From my perspective, the most important thing is to understand that 60% to maybe 80% of people with various addictions have some co-occurring psychiatric disorder, such as depression, anxiety, PTSD, or trauma,” says Dr. Renner.

“There’s fairly clear data that if people don’t get dual-diagnosis treatment, that combines treatment of addiction with treatment for their psychiatric problems, their relapse rates are likely to be high,” he says. “Successful recovery needs both types of conditions to be treated.”

“Less than 10 percent of individuals who have both mental health and addiction problems get treated for both, and it’s important to treat both,” Dr. Muvvala says.

Choices Matter

As with anything in life there are those who want to get involved, and those who possibly would rather not. The syndrome isn’t unique to psychiatry, but to medicine in general, says Dr. Renner. The effect trickles down.

“For many decades, medicine has not been very engaged in treating addiction,” he says. “There is an issue of stigma that’s generally pervasive in society. When a psychiatrist picks up on the fact that a person has an addiction, they may try to refer them somewhere else.”

Some doctors may simply not feel that addiction treatment is for them. “If you don’t treat opioid dependency yourself, cultivate a relationship with a colleague that does so you can refer,” says Dr. Parks. “Then they can coordinate care with the mental health care you provide.”

One of the largest and most positive expansions in the mental health field has been the requirement that certified community mental health centers provide medication-assisted treatment, he says. “All of them have at least one psychiatrist that does prescription treatment for opiate addiction.”

He thinks his fellow psychiatrists really do want to do something about the magnitude of this problem. “Psychiatrists always feel pressure to do more, there’s such a shortage of them,” he says. “We often don’t feel as much pressure from the patient as we do from colleagues in the healthcare system and from ourselves.”

Get Trained Here

Consider these two opportunities to get trained in treating opioid use disorders. Dr. Muvvala points to an excellent resource in the Providers Clinical Support System, funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and designed to support health care providers who treat opioid use disorders. The project is led by the AAAP and counts members from the most visible national organizations that are invested in the opioid crisis.

The AAAP also offers an “Addictions and Their Treatment” course at its annual meeting in San Diego this year, Dec. 3 – 5. Come one, come all, invites the AAAP—including psychiatry residents—to learn more about substance use disorders or get help preparing for subspecialty certification in addiction psychiatry and Maintenance of Certification.