Introduction
Patients with substance use disorders present to every medical specialty, especially primary care, yet many primary care providers feel unprepared to handle these patients. Providers receive little to no training on addiction screening, diagnosing, or treatment. This lack of preparedness, coupled with pervasive stigma, can lead some providers to bias. They may think, “We don’t treat ‘those’ patients. They are ‘dangerous.’ They are dirty. It’s their own fault they are in this situation.” Some providers have the perception that people with substance use disorders “take up too much time” and are “too complicated,” because they don’t know how to manage them. “Why don’t they get help? Why do they keep using? Why don’t they ‘just say NO!’?”
In 2022, among the 4% of US adults who needed opioid use disorder (OUD) treatment, only 25% received recommended medications.1
What do we do? Let me tell you about a patient of mine…
MS is my patient. She came from an intact religious family and denied experiencing any child abuse. She is attractive and friendly, and when she was a teenager she quickly got involved with the “wrong men,” who would physically and emotionally abuse her. They introduced her to drugs and the drugs helped her with the shame and pain of the abuse. She started with marijuana at age 13, and then her ongoing anxiety and depression led her to use illicit alprazolam (Xanax) and clonazepam (Klonopin). Then, she tried stimulants in college along with cocaine and alcohol. After college, she was actively using IV heroin. This went on for many years.
MS tried a few different rehabs, but she felt shame and guilt and embarrassment, and so she never stayed; sobriety eluded her. However, one night, she was in a hotel room using with her boyfriend and some friends, and instead of feeling great, she began to feel very sick. She passed out. Luckily, her accomplices had some Narcan and they helped to save her life. She woke up suddenly, but then she felt worse. She remembers feeling like she was dying.
Someone called 911 and she was brought in to UNC Hospitals in Chapel Hill. Luckily again for her, there is now an addiction consult service on the inpatient unit of UNC Hospitals where patients can be started on buprenorphine/ naloxone (Suboxone) in-house. Suboxone is a partial opioid agonist that can alleviate withdrawal symptoms so people can start their sobriety and begin to rebuild their lives. MS wanted to get help. Now was the time and she took the chance.
Nobody wakes up and decides they are going to be addicted to drugs. For most, it’s often a combination of trauma, bad luck, and bad decisions. Using hides the pain. There is no sadness, loneliness, loss, shame, or disappointment, so you use again. And again, and again, and again. And then you are at the bottom of a deeper and deeper hole that you rarely can get out of alone.
And you feel badly. And you try to get help, and you are met with…
Lack of resources. Only about 20% of patients with opioid use disorder even get treatment they need.2
Stigma. People can be mean. “You chose to do this, what’s wrong with you?”
Shame. “Why can’t you just stop?” “You’ve been to rehab now how many times?”
Our current medical system—society, really—makes it so difficult to get help. Rules of most treatment centers dictate that people must be present at an exact time, use no other drugs, “change your friends, walk away, get a job,” and “just say no!” If only it were that simple. Do we tell someone with a broken leg to “just walk it off”? Do we tell someone with cancer to “just get better!”?
There are many outdated requirements in the system for treating addiction. The system is currently not adequately educating health care providers but also, in many cases, is even preventing patients from accessing care. Buprenorphine originally required waiver training and restrictions on the number of patients providers could see. Methadone is prescribed under antiquated and strict regulations. Insurance dictates the medication dosing, and every day providers have to battle with insurance companies to provide quality patient care. Administrative burdens, bureaucratic drains, and insurance problems abound, causing more and more work for health care providers in our already overburdened medical system.
MS was started on suboxone in the hospital, and she did well. Her body healed (from sepsis, MRSA endocarditis, positive Hep C). It stopped the cravings and made her feel “normal” again. Upon discharge, she was treated in the UNC Substance Treatment and Recovery (STAR) addiction outpatient clinic, and she quickly stabilized. Then, she was transitioned to her primary care office. Fortunately, she was seen by a provider trained to treat SUD. The STAR network has been developed through Dr. Robyn Jordan in UNC’s Department of Psychiatry and is a hub and spoke model designed to provide addiction treatment to patients in the acute phase of addiction. Patients are then transitioned to area providers for ongoing care. The STAR network and its three hubs (UNC Chapel Hill, East Carolina, and Mountain Area Health Education Center) provide educational resources, mentorship, and technical assistance and collaborate with 30–40 area health centers throughout the state. This is valuable training for providers and clinics who encounter these patients.
I worked with MS for a few years and watched her blossom. She lived with her parents and began working in a local bakery and tutoring kids. She took some online classes and eventually got her bachelor’s degree. She healed fully and now teaches pickleball. She recently got married and she is pursuing a master’s in teaching. Not all patients are so successful, but I will tell you that working with people with substance use disorder is some of the of the most rewarding work I do.
Some providers are scared of patients with substance use disorders, but these patients are really just people struggling like all of us and coping in a different way. If we see them and accept them and treat them with respect, they have the capacity to flourish. If we can see their humanity, then we can save lives, and what can be more rewarding than that?
Disclosure of interests
Amy Ford works with the STAR Network but was not financially compensated for this article. No further interests were disclosed.