There was a very interesting commentary in this week's New England Journal of Medicine. In it the authors describe a case from their infection disease practice of a young man with infectious complications of intravenous heroin use ( Staph. aureus tricuspid valve endocarditis, septic arthritis, and empyema). He had a history of doing well on buprenorphine maintenance in the past and was offered that treatment again by the Infectious Disease (ID) team as he was leaving inpatient hospital. They completed the induction phase on the afternoon of discharge and he was discharged on buprenorphine-naloxone (Suboxone). The ID faculty at Beth Israel Deaconess Medical Center, a large tertiary care hospital in Boston have all been certified as buprenorphine prescribers and present this as an option to all of their patients with infectious complications of intravenous substance use. In addition to the buprenorphine they also provide rescue naloxone to treat acute opioid overdoses, discussions about harm reduction, injection practices, and cravings. In the case that was presented, there was a discussion of the relapse risk and risk of recurrent infection or death from an accidental overdose.
This group of physicians has provided an outstanding example of what can be done when you are working with a highly motivated group who seizes the opportunity to make a significant difference. Part of their discussion is in terms of expanding their practice outside of the traditional role and expecting some pushback on that. As I read their report, I thought about how this process might occur within the usual hospital setting. A psychiatric consultation would be placed. In tertiary centers a psychiatrist would see the patient, make a detailed assessment and recommend outpatient care somewhere. That psychiatrist may or may not have a buprenorphine license. Depending on location, there may not be a buprenorphine provider to refer the patient to. In the case of intravenous heroin use that practically guarantees a relapse to heroin at the time of discharge with the attendant mortality and morbidity. In this case the patient is familiar with the same treatment team that discusses the issue with him and gets him on Suboxone prior to discharge. In today's world of rationed medical care - I cannot think of a more perfect intervention for high risk patients from an addiction standpoint.
The use of buprenorphine to treat opioids use disorders is not a perfect solution but it helps a large number of patients remain abstinent in general treatment populations. The patient described in this paper was perhaps more highly motivated than most due to his complicated illnesses. The authors experience reflects the fact that they clearly know the treatment process is complicated but view what they are doing as a bridge to long term care for opioid use disorders. I agree with them completely.
There are a few considerations that they did not touch on that I think are important. The personal characteristics of the physicians in this group is a major factor. They discuss the history of their specialty as one that values social justice and public health. They suggest this was a primary factor in allowing them to not get caught up in the stigma of treating addicts and the associated lack of resources. I witnessed this first hand in the 1980s and 1990s when ID physicians and clinic staff were dealing with the HIV epidemic. That went on for years before there was adequate treatment and the death toll was high. Many ID clinics provided critical support to patient and their families during that time. I don't think that they ever got any recognition for that role. Treating addiction above all else takes emotional neutrality and that was a characteristic I observed first hand in HIV clinics.
I certainly hope that this group gets the credit for innovation and hard work that goes with this approach. They mention a couple of other groups who have picked up on this approach. At the same time I have concerns about how other groups may view this article. The billing and coding system and clinic structures are generally not setup to allocate enough time to deal with two very complicated problems. In the outpatient setting, sober homes set up to deal with the substance use and medical complications are extremely rare. In some cases, sober homes and halfway houses refuse to accept patients taking Suboxone or other potentially addictive drugs. It takes dedicated social work or case management staff to negotiate those problems. It also takes some level of administrative support to know that discharging a patient as soon as possible when they are in opioid withdrawal makes little sense.
Time and burnout are also relevant factors. The primitive state of productivity based medical administration needs to be able to accommodate this level of complex care and allot physicians enough time to provide both medical and addiction services. I have over 20 years of experience in providing both medical and psychiatric services on inpatient settings. Even though I enjoyed doing it - there was a tremendous time penalty associated with the additional work and that can easily lead to burnout. If addiction care expands among specialists and generalists - they need the additional times and reimbursement to provide this level of care.
None of these considerations detracts from the accomplishment of this department of infectious disease doctors. Taking on this additional role is especially striking in an era where patients are told that they can only discuss one problem per clinic visit with their doctors. This approach is a shining example of the highest level of medical professionalism and my hat is off to them.
George Dawson, MD, DFAPA
I certainly hope that this group gets the credit for innovation and hard work that goes with this approach. They mention a couple of other groups who have picked up on this approach. At the same time I have concerns about how other groups may view this article. The billing and coding system and clinic structures are generally not setup to allocate enough time to deal with two very complicated problems. In the outpatient setting, sober homes set up to deal with the substance use and medical complications are extremely rare. In some cases, sober homes and halfway houses refuse to accept patients taking Suboxone or other potentially addictive drugs. It takes dedicated social work or case management staff to negotiate those problems. It also takes some level of administrative support to know that discharging a patient as soon as possible when they are in opioid withdrawal makes little sense.
Time and burnout are also relevant factors. The primitive state of productivity based medical administration needs to be able to accommodate this level of complex care and allot physicians enough time to provide both medical and addiction services. I have over 20 years of experience in providing both medical and psychiatric services on inpatient settings. Even though I enjoyed doing it - there was a tremendous time penalty associated with the additional work and that can easily lead to burnout. If addiction care expands among specialists and generalists - they need the additional times and reimbursement to provide this level of care.
None of these considerations detracts from the accomplishment of this department of infectious disease doctors. Taking on this additional role is especially striking in an era where patients are told that they can only discuss one problem per clinic visit with their doctors. This approach is a shining example of the highest level of medical professionalism and my hat is off to them.
George Dawson, MD, DFAPA
1: Rapoport AB, Rowley CF. Stretching the Scope - Becoming Frontline Addiction-Medicine Providers. N Engl J Med. 2017 Aug 24;377(8):705-707. doi: 10.1056/NEJMp1706492. PubMed PMID: 28834479. (free full text).
