The Opioid Epidemic and Psychiatry: The Time for Action Is Now

Because substance use disorders commonly co-occur with other disorders (i.e., mood, anxiety, and personality disorders) and are a risk factor for suicide, psychiatrists in all settings must screen for substance misuse in addition to mental illnesses. In the NESARC-III, lifetime opioid use disorder was associated with higher rates of posttraumatic stress disorder in men and women, mood disorders in men, and other anxiety disorders in women (2). Furthermore, severe mental illnesses and opioid use disorder commonly co-occur (7). For optimal detection and treatment of opioid use disorder, addiction psychiatrists in specialty settings can address the disorder and co-occurring mental illnesses. Psychiatrists in other settings can increase screening and detection of opioid use disorder for patients with mental illness by asking all patients—at intake and regular intervals thereafter—about substance use and problems related to use by using tools such as the National Institute on Drug Abuse’s NIDA-Modified ASSIST. Information from other sources (e.g., families), including biological tests (e.g., urine drug screens), may also be helpful. Failure to address opioid use disorder in patients with depression, anxiety, and other disorders will likely result in poor outcomes and patient dissatisfaction with the care they receive.

After diagnosing an opioid use disorder, psychiatrists can work with patients to identify treatment goals, which may include reducing or abstaining from risky substance use. Using shared decision making, psychiatrists can help patients select among treatments that are best matched to their preferences and treatment goals and can then either treat patients or refer them to the appropriate care. Psychiatrists may either assist in transitioning a patient to providers with expertise treating opioid use disorder, comanage patients along with opioid use disorder specialists, or manage the opioid use disorder pharmacotherapy and other treatments themselves. Given the urgent need to increase treatment capacity in the United States, all psychiatrists should develop skills to diagnose and offer basic treatment for opioid use disorder and should be able to coordinate with other providers to care for patients with acute or complex needs.

Cases of opioid use disorder range from straightforward to complex. After a comprehensive assessment, psychiatrists can ensure that behavioral and psychosocial treatments are provided to address co-occurring addiction and mental illnesses as well as housing, employment, and social support needs. In addition to collaborating with colleagues, outcomes can be improved by incorporating family, peers, and community members into team-based treatment. Finally, it is important to instill hope and reduce stigma by using person-centered and recovery-oriented language with patients and care providers.

Pharmacotherapy for opioid use disorder is safe, effective, and critically important for improving outcomes and preventing accidental overdose. Methadone, an agonist with a half-life of about 1 day in tolerant individuals, can be dispensed only in federally licensed programs. In contrast, buprenorphine can be prescribed in an office-based practice. An opioid partial agonist with a half-life of 1–2 days for people who have recently used opioids, buprenorphine is delivered either sublingually with naloxone (i.e., Suboxone) to prevent injection abuse or in long-acting injections and subcutaneous delivery devices. To prescribe buprenorphine, physicians can undergo 8 hours of training and obtain a waiver certification. As of 2012, 2.2% of U.S. clinicians had obtained waivers; among those with waivers, 41.6% were psychiatrists and 36.7% were primary care providers (8). Availability of buprenorphine providers varies greatly, with fewer providers in rural areas and the Midwest, but is generally low in relation to the size of the population in need (9). Naltrexone, an opioid antagonist, is available in daily oral and extended-release depot forms for people who have completed withdrawal. This medication may have lower acceptability but is an important option, especially for people with mild disorders and for those who have not responded to other approaches. Additionally, benzodiazepines, which contribute to risk for accidental overdose, should be avoided. Finally, a prescription for naloxone, an effective antidote to opioid overdose, can allow family and friends of the patient to administer the medication in case of accidental opioid overdose.

Expanded use of office-based pharmacotherapy to treat people with opioid use disorder could dramatically increase access to treatment and enhance treatment quality. To facilitate psychiatry’s expanded involvement in office-based treatment of opioid use disorder, several factors require attention: intervention and practice workflow, provider beliefs and willingness to work with the patient group, and environmental characteristics, such as reimbursement policies.

Addressing structural and systems issues for each of the evidence-based pharmacotherapy options to treat opioid use disorder can facilitate treatment delivery. First, psychiatrists using these medications must develop the systems to track prescriptions and provide records to federal auditors (for buprenorphine prescriptions). Second, psychiatrists must have on-site capacity to confirm substance use, abstinence, and withdrawal symptoms. To receive buprenorphine, patients who use opioids must be in a confirmed state of withdrawal and must be monitored during repeated dosing over the first few hours on the first treatment day. A system whereby nurses offer in-office monitoring can be developed. Alternatively, home-based induction is becoming more common (10). To receive naltrexone, patients must be opioid free for 7–10 days prior to taking the medication in order to avoid precipitating withdrawal. Third, providing extended-release naltrexone via an intramuscular injection requires either a system and licensure for refrigerated storage or relationships with pharmacies that store and deliver this medication. Some providers require that patients pick up their medications and bring them to the office on the day of medication delivery. Fourth, during pharmacotherapy for opioid use disorder, prescribers must monitor periodic urine drug screens to track ongoing illicit drug use, guide dosing adjustments and psychosocial treatments, and confirm medication use to reduce diversion. Fifth, psychiatric providers must have the capacity to provide or refer patients to behavioral and psychosocial interventions, which many patients need to maintain abstinence and advance their recovery. Finally, insurance coverage and cost of these interventions must be addressed.

Clinicians are more comfortable providing treatment when they have adequate knowledge and office workflows that support and inform the treatment. The Substance Abuse and Mental Health Services Administration now supports access to free Web-based and in-person training and ongoing peer supervision through programs such as the Providers Clinical Support System (https://pcssnow.org). In clinics with multiple clinicians, experts can help administrators create supportive workflows—including standard processes for buprenorphine inductions, urine drug screens, documentation, and peer consultations—for all clinicians. In larger systems, clinician interventions, such as academic detailing, can enhance knowledge and improve prescribing. In coordinated, “stepped” care, such as the hub-and-spoke model tested in Vermont (11), providers deliver treatment at a particular level of intensity and refer patients to other providers for care at different levels of intensity. This model can enable specialty care during intensive treatment phases followed by a “step down” to local treatment by nonspecialists. Thus, relationships with colleagues and facilities that can care for patients with severe disorders can ease any concerns clinicians with less experience may have about providing care. Finally, if there is to be a shift in the culture of psychiatry, it is time to ensure that, at a minimum, all psychiatrists-in-training receive buprenorphine training.