Patients seeking treatment for substance use disorders have traditionally been directed to specialists, but what if they could see their primary care provider and receive a prescription that treats this disorder at the same time as they are discussing their overall health and receiving other medications and refills? This model of treating addiction in the primary care setting is slowly emerging, and it’s one of the important ways that BWH is working to increase access to care for patients suffering from opioid use disorder.
Two nurse practitioners are at the forefront of this effort. Elizabeth Donahue, MSN, RN, NP-C, and Kate Takayoshi, MSN/MPH, RN, NP-C, of Brigham and Women’s Primary Care Associates, Longwood, have completed the federally mandated training to prescribe buprenorphine, a drug that treats pain and addiction to opioids.
“Addiction is a disease, and we can treat it in Primary Care,” said Donahue, who also serves as a professional development manager for Primary Care. “It’s a big barrier for a patient to walk into a new treatment center or clinic and say they need help because of the stigma that exists around addiction. But patients already have established relationships with their primary care providers, and they are already seeing us for other needs. It would make it much easier for my patients if I could treat their substance use disorder, including providing medication-assisted treatment, like Suboxone (a combination of buprenorphine and naloxone) as I’m managing all of their other diagnoses.”
Donahue is waiting to receive her waiver from the U.S Drug Enforcement Agency (DEA), which will allow her to begin prescribing buprenorphine, per the requirements of the Drug Addiction Treatment Act of 2000. Even after completing the training and receiving waivers, providers are limited to prescribing for 30 patients concurrently in the first year, 100 in the second and 275 afterward, upon receiving approval. BWH Primary Care leadership is focused on facilitating the training process for providers so that more will complete it and expand access to treatment. Physicians must complete eight hours of training, while nurse practitioners and physician assistants with prescribing privileges, like Donahue and Takayoshi, undergo 24 hours of training.
As of August, it is estimated that fewer than 4 percent of prescribers nationally were waivered to prescribe buprenorphine.
“Primary care providers aren’t required to treat these patients, so it’s up to individuals to express interest in doing so,” said Donahue. “We need all hands on deck to care for these patients, particularly considering that many of them became dependent on opioids prescribed by a provider for pain management over the last two decades.”
B-CORE and the Bridge to Recovery
The Brigham has been taking steps to tackle opioid use disorder from multiple angles. In previous years, a comprehensive outpatient program for substance use disorders was launched at Brigham and Women’s Faulkner Hospital, including an intensive Partial Hospital Program. At the Jen Center, a novel program to treat opioid use disorder was implemented where a psychiatrist, pharmacist and health coaches work together to provide treatment for opioid use disorder in the primary care clinic. More recently, the Brigham Comprehensive Response and Education (B-CORE) Program was established. The program’s initiatives include developing standardized guidelines for prescribing opioids, improving access to naloxone to help reverse overdoses and increasing access to addiction treatment for patients.
Earlier this year, B-CORE took a major step forward with the opening of the Brigham Health Bridge to Recovery, or “Bridge Clinic.” After being discharged from inpatient units or the Emergency Department, patients who need treatment for a substance use disorder are immediately referred to the clinic and receive access to pharmacotherapy, individual and group counseling, case management and peer support. Prior to the clinic’s opening, patients needed to wait several weeks for an intake appointment at the outpatient clinic at Brigham and Women’s Faulkner Hospital– a result of the extremely high demand for treatment for opioid use disorder.
This month, Takayoshi became the first nurse practitioner to begin seeing patients in the Bridge Clinic, joining a group of physicians and multidisciplinary staff, one morning a week.
“Our goal is to get high-risk patients started with the medications and services they need immediately, then help them find the right program to support their recovery,” she said.
The Bridge Clinic has steadily grown its volume, with about 130 patient referrals since its opening in April.
“The Bridge Clinic opening has given us an important opportunity to treat more patients with addiction issues, including opioids, alcohol, cocaine and other substances,” Takayoshi said. “It’s a critical way to catch patients while they are in the hospital and connect them with the treatment they need because any outreach a patient must do on their own can be a barrier that ultimately prevents them from receiving treatment.”
Hope for the Future
Both Donahue and Takayoshi are optimistic about the work that the Brigham has already done and hopeful that more patients with substance use disorders will receive the treatment they need and prevent deaths caused by overdose.
“Addiction medicine has come a long way, but there is so much more we need to do to ensure every patient suffering receives the treatment they need to recover,” Takayoshi said.
Visit BWHPikeNotes.org to for a calendar of Brigham Health events throughout September in honor of National Recovery Month.