Michigan doctors not trained to treat opioid abuse ‒ and don't want to be

Opioid addiction

Most Michigan primary doctors surveyed said they are not interested in undergoing training in medications that can treat opioid abuse. Michigan lags the nation in the availability of doctors trained to administer these medications. 

As Michigan continues to lack enough resources to treat opiate addiction, a statewide survey finds just one in five primary care physicians offers medication assisted treatment in their practice.

And according to the survey of roughly 600 primary care physicians by the University of Michigan’s Center for Health and Research Transformation, even fewer are interested in being trained.

Audrey Smith

Audrey Smith of the Family Medical Center of Michigan: “You want to get people back to being productive citizens again.” (Courtesy photo)

“It’s a culture issue. There’s an implicit bias that persists [among some physicians],” said Molly Welch-Marahar, an opioid treatment expert who analyzed the survey for the center. 

Welch-Marahar speculated that physicians who practiced in the early 2000s – when powerful opioids like OxyContin were marketed as a pain treatment that posed little risk of addiction – may be slow to see the potential in new treatment methods.

“They were trained to believe that opioids were a tool to solve a problem, not a problem in itself.”

Many addiction experts consider medication-assisted treatment the gold standard of treatment for opioid addiction.

This approach uses opiate substitutes such as methadone – which is most often dispensed at a clinic – or buprenorphine, which can be prescribed by a primary care physician and taken home by the patient. Such treatment is often combined with some form of behavioral counseling.

Molly Welch-Marahar of the Center for Health and Research Transformation, says of some physicians: “There’s an implicit bias that persists.” (Courtesy photo)

Under the federal Drug Addiction Treatment Act of 2000, physicians are required to finish an eight-hour training course before they can prescribe buprenorphine or similar medications. Physician’s assistants and nurse practitioners can prescribe if they complete a 24-hour course.

According to a 2018 analysis by Avalere Health, a Washington, D.C.-based healthcare consulting firm, Michigan ranked in the bottom 10 states in the ratio of certified doctors compared to the number of opiate deaths in the state.

Michigan tied for sixth worst in the ratio of buprenorphine prescribers to opiate deaths, according to Avalere, with .39 prescribers for every opiate death – compared to the national average which is four times higher (1.6 prescribers per death). 

Opioid overdose deaths, meanwhile, nearly tripled statewide over a five-year period, from 681 in 2012 to 1,941 in 2017, the last year for which data are available.  The number of opioid deaths for 2018 has not been released.

The death toll in recent years has been fueled by street drugs laced with fentanyl, a synthetic opioid that now accounts for far more deaths than prescription opioids. It is considered 50 times more potent than heroin.

The Michigan survey found older physicians are less likely to be interested in training to offer medication-assisted opioid treatment. Of those with 10 to 19 years of practice, 68 percent were not interested in training, with just 13 percent saying they are  interested. Among those with at least 20 years of practice, 65 percent were not interested and just 16 percent were interested.

Even among younger doctors, those with less than 10 years of practice, 50 percent said they were not interested in being trained – while 26 percent were interested. 

Survey results were also mixed on recent state-ordered reforms intended to rein in opioid abuse. Among other things, the new rules include a seven-day limit on opioid prescriptions for patients in acute short-term pain, and a requirement that doctors check a state database system before writing a prescription, which is intended to prevent patients from seeking opioids from multiple doctors.    

The CHRT survey found that 60 percent of doctors say the state prescription system is useful in addressing the opioid crisis. Even so, 70 percent said state reporting requirements imposed an “unnecessary administrative burden.”

A couple years ago, the Family Medical Center of Michigan, which serves about 20,000 patients in Monroe, Lenawee and southwest Wayne County, had just two doctors certified to prescribe buprenorphine.

But it arranged training for four more doctors in spring of 2018, to help it meet demand.

Audrey Smith, the center’s chief operating officer, said it only makes sense to bring as many resources as possible to this fight.

“Why this matters is that now there is an option to help folks get off their addictions,” she said. “It’s not [medication-assisted treatment] alone. It’s coupled with therapy. We have therapists to help people get through issues.”

Smith said the center’s physicians consult at times about tricky addiction cases with specialists from the Michigan Opioid Collaborative, which is seeking to build the state’s treatment network. That’s one more tool to close the treatment gap.

“You want to get people back to being productive citizens again,” Smith said.

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Fri, 07/12/2019 - 8:34am

Doctors are like most people they want to see results from their efforts. The more direct the better. And they are limited resource. . Addicts are extremely dishonest. The relapse rates are incredibly high . Is it any surprise Docs want to use their efforts where they do the most good?

Fri, 07/12/2019 - 9:35am

McLaren Lapeer Hospital Pain Clinic needs trained in taking people of prescription opiates properly they had been prescribing . My Husband went there for two years 5 different doctor's during that time in his last 3 visits he saw a different doctor. After the MAPS was passed ended of 2017 on his Jan 9 2018 he was told he was getting taken off Norco. He got put on Lyrica 50 with no follow up until March 20 he had written prescription to go up to 100 mg on Jan 30 . On Feb. 2 he ended up in hospital for a Suicide attempt plus ended up with charges because I called 911 for help. He was pushed of our porch as I yelled he has a prosthetic leg then tased twice when he was on the ground. All in 14 seconds of our screen door being opened by a police officer. I was told that night by the officer who opened the screen door & wrote the report he had to be charged because they used force. In that report he said he had minor jaw pain from POSSIBLE being hit. When he went back on March 20 they kicked out of the pain clinic because he overdossed on the Lyrica even though they had access to his medical records . He named the pain clinic said he he was upset about the pain that they took him off Norco & up his Lyrica he said it wasn't working. On another paper he mentioned he tring to get high so that should have flagged he needed treatment for addiction. It also said secondary to the nature of patients illness or personality structure he was a chronic risk for Suicide. They didn't say that at the family meeting. It even says guns in the house that he had no access to .( because I hid the keys) He went to court for sentencing judge added to plea deal two weeks later he broke into the gun safe while I was at work & our son was at summer school. Two day's before he brought up about them cutting him off the pain pills. He took Tylonal pms (that's what he was using for his pain) bought a bottle of liquor & shot himself in the head. Yeah they prescribed almost half the opiates in 2018 then they did in 2017 beasuse of MAPS at a cost of people's lives. He got his medical paper's the week before he gave the probation officer a copy of psychiatrist report. I have been looking at them.

Fri, 07/12/2019 - 9:49am

Matt - If opiod deaths have tripled and they are unwilling to use effective treatment apparently Drs. aren't concentrating their efforts where they would do the most good. It would appear quite the opposite.

Fri, 07/12/2019 - 7:44pm

But you haven't answered whether it would help more with addicts or do more good elsewhere. Since you mentioned it, tell us what is an effective treatment. I know several families that would love to know.

Fri, 07/12/2019 - 2:21pm

This is the root cause. If they didn't want to be trained they shouldn't have overprescribed and fed the world with the poison that's now killing us. For everyone not wanting to that should be one less doctor practicing in the state. Take their license. Or better yet, do to them what the nation does to the victims. Lock 'em up. Then when they get out, make sure they have zero chance at making their way back towards anything for the better part of 18-36 months. Maybe then they might consider things like Hippocrates and purpose for service in the first place.

Fri, 07/12/2019 - 3:36pm

This is why we need Medicare For All. Parts of this article are practically verbatim to a conversation I had with one of my doctors. I am a responsible Tramadol user and my Primary wanted to wean me off entirely. I was taking a low dose of two 50 mg tablets a day for my chronic pain brought on by several conditions, and it wasn't enough. I barely made it through the winter months and wanted to raise my dose by one tablet, or to three a day AS NEEDED. My Primary refused so I asked my spine doctor if he would do it. He agreed but said he wasn't sure how long he would be able to keep it going because he was sick and tired of all of the "administrative paperwork" since the new regulations came out, and he's thinking of retiring early, (I'm guessing that he is in his early 60's at most). "A lot of my patients are" coming to him scared about losing their opioid treatments.

Another problem is the doctors who are removing opioid treatments aren't coming up with comparable alternatives in their place. I was offered OTC lidocaine patches to compensate which really can't compare. OTC pain killers just can't touch the kind of pain I experience on a daily basis, let alone if I am having a flare up. I'm not addicted to Tramadol, but I am in pain all of the time. I have no problem with a non-opioid treatment plan but it has to work. It's a matter of getting to a semi-functional level or being unable to leave my home.

So what I guess I don't understand about this training dilemma is why it's a choice in the first place. It should be mandatory training, period. Do you want to keep your license current? Do the training. Or, make it a requirement of staff members so that you can have enough trained personnel on hand at any given time. Had they rolled this "plan" out the right way--oh nevermind, we're talking about the current government. So many no-brainer moments.

Fri, 07/12/2019 - 3:48pm

I suspect among doctors there might be a stigma in dealing with opioid abusers, they might consider it something for social workers to deal with and not doctors so they would rather just wash their hands of the whole situation.

Sat, 07/13/2019 - 10:59pm

*** Addict's families can't deal with them, why would anyone think that an unrelated doctor is going to have better luck? There is no magic cure they can pull out of their bag.

Sat, 07/13/2019 - 1:31pm

If the doctors don't want to do it, let the advanced nurse practitioners do it. We have master's and doctorate prepared folks....but not enough. Right now, Michigan regs don't let these practitioners work independently (as they do in other states), so it's not an attractive option for students. The doctors don't want to care for this population but their PAC will pay attention if the nurses lobby for independent practice after graduate training in a specialty. We can't take care of people in the current model.

Lesly Pompy
Sat, 07/13/2019 - 3:27pm

Doctors trained to treat pain and Opiods abuse get raided, arrested, loose their medical license, loose their DEA registration, suffers Civil Assets Forfeiture, get Blamed for illegal drugs coming from Mexico and Afghanistan,and get indicted for allegations of practicing medicine “ outside the legitimate practice of Medicine.” Doctors caring for the patients with substances misuse ,take substantial, unjustifiable risk to the their medical license. It is best to let law enforcement fills the jails.

Bob Schubring
Sat, 07/13/2019 - 4:19pm

Actually there's a deep-seated prejudice among young people who got their medical knowledge from watching "Chicago Med" and "Grey's Anatomy", that patients don't deserve any say in our own care. It is because of that deep-seated prejudice that myths about addiction, which were disproven for 3 decades, persist. Complicating matters is wishful thinking about the beneficial effects of marijuana, a lethal combination of prejudices if we are to reach a healthful consensus among our population.

To begin with, cannabis contains a potent anti-anxiety drug called cannabidiol, (CBD) mixed with a hallucinogenic drug called Tetrahydrocannabinol (THC) that causes anxiety. Consuming CBD is a way to alleviate anxiety and relieve muscle tension. Depending on one's tolerance for THC, one's reaction to various strains of the cannabis plant will vary. Some people will get worse and others will get better. The body's Endocannabinoid System uses no THC nor CBD at all...it runs on a different substance called Anandamide, that's made in the liver from an alkaloid found in peanuts. Pain that's primarily caused by anxiety, such as happens in muscle-tension headache, often responds well to some CBD.

Pain that's primarily caused by trauma is the province of the endogenous opioid system, often called the "endorphin system". Here's where a Chicago Med TV education gets sketchy: What the TV writers never tell you, is that so-called "endorphins" are actually the same substance, in every species of plant and animal alive. All eukaryotic organisms make morphine from the amino acid tyrosine, and use it to control the rate of metabolism in our intracellular mitochondria. A eukaryote with deficient morphine secretion dies, because it's mitochondria literally eat it and burn it up into energy. Morphine slows metabolism during the sleep cycle, then washes out of the body in our urine as dopamine accumulates, causing wakefulness. One of the reasons people feel jet lag when traveling to another time zone, is that this biochemical clock is set to our normal waking and sleeping hours at our home, and takes several days to re-set itself to a different time zone.

The primary difference between natural opiates that are extracted from poppy plants, and synthetic opioids like fentanyl and buprenorphine, is that the natural opiates all degrade in the liver to become morphine, and wash out in the kidneys. Oxycodone, for example, passes through one liver enzyme that removes the oxygen, creating codeine, and a second enzyme that converts the codeine to morphine, after which the morphine washes out in the urine. The long-acting effects of oxycodone are due to the fact that both it's metabolites also have analgesic effects. The synthetics often have incompletely-understood metabolic pathways, and we don't really know what the long-term effects of buprenorphine or fentanyl or methadone actually are.

When he was a young gullible endocrinologist, California opioid expert Dr Forest Tennant consulted with Nixon's brand-new DEA and sat in on the meetings where the Nixon team proposed taking Nazi Germany's synthetic substitute for heroin, the drug called Methadone, out of obscurity and using it for medication-assisted therapy of heroin addicts. Dr Tennant recalls that the main reason the Nixon team chose Methadone, is because the strange metabolites it forms in the liver, are easily identified by gas chromatography. What Nixon's team wanted was a way to make sure that addicts were getting enough methadone that they weren't adding real heroin to it, to maintain themselves in their condition. What none of the Nixon men even thought about, was that the Methadone metabolites might be more toxic than heroin.

Continued Nixonism in medicine, thanks to ignorant TV propagandists who repeat silly things they heard elsewhere, now has us using toxic fentanyl because synthetic heroin is legal but real heroin isn't. Countries like Britain and Portugal and Switzerland, which never took heroin off their formulary, continue to use cheap heroin to treat end-stage cancer pain and other intractable pain. We Americans, addicted to the nonsense spewed by TV writers, insist on giving highly toxic synthetic pain drugs to these patients, smug in the belief that "we're not giving them heroin".

That's why there's a legal issue over long-term fentanyl use. NIDA scientists have 30 years of research that conclusively proves morphine causes no buildup of toxic residues over time. People urinate and it's gone. And it was already in our bodies to begin with. There are multiple unknowns about fentanyl and it's homologues, as there are about buprenorphine. The combination of naloxone and buprenorphine has low acute toxicity, because taken by itself, one does not lose consciousness from an overdose (although mixing it with fentanyl, all bets are off). Suboxone, the buprenorphine - naloxone mixture, is favored for medication-assisted therapy in case the addict attempts suicide with it, but that was before illicit fentanyl became a profitable sideline for the Mexican methamphetamine-and-cocaine cartels.

The irony of Dr Tennant's story doesn't end there. He continued researching drug abuse and treating patients with intractable pain. Intractable meaning "so severe that the patient can't think of anything else but how to stop the pain". One disease that causes such Intractable pain is Adhesive Arachnoiditis, a condition when allergic inflammation or infection sets up inside the lining of the spinal cord, and adhesions develop that glue the spinal nerve to the lining, literally making any movement of the body agonizing. President John F Kennedy caught this disease from a medical procedure done to diagnose a back pain he got in the sinking of PT 109. Doctors injected his spine with a contrast agent, trying to see on X-ray photos if there was a bone spur, fragment of enemy ammunition, or some other abnormality that was causing his back pain. He turned out to be allergic to the contrast agent and ended up with disabling intractable pain...serving terms in the Senate and the White House on a stiff dose of morphine to keep the pain sufficiently controlled so that he could focus on his work. Arachnoiditis is more painful than any known form of cancer. Only one disease causes worse pain than Arachnoiditis, a condition variously known as RSD or CRPS, in which the nerves themselves begin degenerating, causing violent pain signals to flood the brain as they slowly die.

Dr Tennant took on a number of Arachnoiditis patients and applied his knowledge of endocrinology, to consider which other systems of the body may be knocked out of balance by this disease and experimenting to see if pain could be better managed by restoring balance to them all. He was invited to Virginia to give a talk about his work, and told the details of one man with Arachnoiditis, whose previous doctor had tried giving him 4 thousand milligrams of morphine daily, and still could not get him relief. Balancing out the man's oxytocin system with some hormones helped immensely. The biggest benefit they found, was putting the man on CBD to calm his nerves a bit. With calmer nerves, the man's need for morphine was reduced. From 4,000 mg a day that was ineffective, to a mere 380 mg a day that proved highly effective, in combination with the CBD,

The doctors at the medical conference thought that was a breakthrough.

On returning to California Dr Tennant found a breakthrough of a different sort. DEA agents had broken down his office door and seized his patient's medical records. The search warrant stated that the agents were investigating whether Dr Tennant had illegally prescribed marijuana, which DEA considers a Schedule I drug, because Nixon told them to ignore a government report advising that it was harmless and should be rescheduled.

Grudgingly, after the FDA approved a pure form of CBD made in Windsor, Canada as a treatment for 2 kinds of epilepsy, DEA assigned CBD to Schedule IV, putting it on a par with another anti-anxiety drug, Xanax. Temporarily, those Arachnoiditis patients have some hope of a normal life.

20,000 people caught Adhesive Arachnoiditis when the New England Compounding Company shipped a defective batch of epidural anesthesia meds that had not been sterilized. The meds contained live fungus.

Numerous young mothers gave birth to a child while under an epidural, only to be hospitalized with meningitis caused by the fungus infection.

Congress in 2012 responded to the Arachnoiditis outbreak, passing the Drug Supply Chain Security Act, mandating that drug makers track every package of medicines they dispense, so that if contamination is suspected, the contaminated meds can be immediately recalled, and not left on hospital shelves where they can continue harming additional victims for months. Drug makers have until 2022 to comply with the new law.

Meanwhile our DEA retains an unhealthy obsession about cannabis and had to be forced by an act of Congress to accept that CBD can be made legally and used to treat patients. Can a CBD/Morphine combination offer better pain control than Fentanyl, with less toxicity hazard? That's a subject that deserves to be researched. Perhaps if finally will be.

middle of the mit
Sun, 07/14/2019 - 1:28am

This situation has gone far too long. Republicans and dems have literally demonized anyone who uses these medicines as medicines.

They think that anyone using them to control pain is an addict. What they don't know is if you these medicines as prescribed, you don't get high.

That's right! If you are in pain and you use an opiate, you will get high the first time. A little. After that? You are just able to live your life.

Now? Try to get an equivalent that comes into cost comparison. $44 vs $750 for time release capsules!

I know! I ask for prices!

What is a person supposed to do?

Go Green!!

Mon, 07/15/2019 - 2:53pm

There are people taking their lives because they have been cut off from their pain meds. No one can walk in their shoes. If you don't have that type of debilitating pain, you cannot imagine it. They should not punish everyone for the few. And it isn't right to lump heroin use with someone who needs opiate pills just to get out of bed. It isn't the same type of lifestyle and it is making some people in so much pain they don't want to live.

middle of the mit
Tue, 07/16/2019 - 11:17pm

I was cut off of my pain meds. That is whole reason I posted the prior post in the first place.

I DO have that debilitating pain! I walk in those shoes every day and conservatives tell me I am a liar too, including my own family.

I never said anything about using heroin to control pain.

I said GO GREEN! Use the CBD's . medical cannabis.

It works.

I KNOW, I have BEEN there and it works. It doesn't as well, but it is cheaper even if you grow it yourself, and it is a lot better for you. If we could just get the conservatives on our side, we could change things.

Instead, us in the northern woodlands are just going to keep on keepin on with the meth and the pharmas.

Go ahead look up any Northern Mi news paper. Look at what happens up here in the court section. You think conservative policies are awesome, check out what they are allowing to happen up here. As a per capita basis, We might rival you for crime.

Sun, 07/14/2019 - 9:45am

If the doctors don't want to do it, let the advanced practice nurses do it. They are hampered by law in Michigan (unlike other states with a large rural population) from practicing independently. This is just another one of the turf wars where the doctors don't want to do it but they don't want anyone else doing it either. These master's and doctorally prepared nurses are expert practitioners in their particular specialities.

Lisa Rutledge
Mon, 07/15/2019 - 3:26pm

I’m going out on a limb and say most doctors should not treat opioid abuse. We certainly need more of them to prescribe the medications. However, working in a practice that does a lot of MAT, I’ve learned that it is most successful in a setting where there are therapists, peer recovery coaches, care managers and other support staff there to treat holistically. We do this like Family Medical Centers does.

It can’t work well for most just with someone writing a prescription.