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It is well-known that people with Substance Use Disorder (SUD) and Opioid Use Disorder (OUD) face a heavy stigma in society at large. For instance, in Victoria, BC, while exceptional caregivers such as Corey Ranger, the roving Narcan-toting nurse are saving addicts’ lives, hostile bystanders often offer disdainful suggestions such as “Oh, why bother? Just let them die!”
Indeed, it is not uncommon for the general public to regard SUD and OUD as examples of societal weakness and personal failure, rather than viewing the condition as a medical condition that is frequently combined with other chronic disorders. In many cases, those suffering from addiction are also subjected to negative attitudes from nurses, doctors, and other healthcare practitioners. As a nurse in one study says of SUD patients, “[they create] a cycle of problems,” where “the staff perceives them to be annoying or obnoxious…” Another nurse in the same study notes, “staff attitudes are obvious, you can’t really hide them that well.” It is acknowledged that “Stigmatizing attitudes among health professionals have been shown to be widespread, which has detrimental consequences for connecting persons with OUD to treatment.”
Nurses, Doctors and SUD; Nurses and Doctors with SUD
There is an irony when healthcare practitioners display this attitude toward patients with SUD and OUD. According to the American Journal of Psychiatry and the National Council of State Boards of Nursing [NCSBN] publication “Substance Use Disorder in Nursing,” the prevalence of substance use disorders among doctors and nurses is similar to that of the general population—and is higher than the general public in the case of prescription drugs.
However, doctors’ tendency to protect colleagues with SUD, and the policy of the NCSBN that promotes a nonjudgmental, stigma-free approach to treatment of nurses with SUD (approximately 70% of nurses who seek treatment successfully return to practice) coexists with strong evidence that a substantial number of doctors and nurses have a negative attitude toward addicted patients. The consequences are as grave as they are incongruous; as a study in Canadian Nurse.com remarked, “perceived discrimination on the part of health-care staff was a major barrier to [patients’] seeking medical help, both for their substance abuse and for treatment of general and chronic conditions.”
Doctors and OUD: A Static System
“Fresh out of medical school, you can prescribe for pain relief any of the opioid medications that can lead to addiction, but you have to get a special waiver to treat addiction, a disease process. That just doesn’t make sense…”–Dr. Sandeep Kapoor, director of the Screening, Brief Intervention and Referral to Treatment (SBIRT) program at Northwell Health
The situation of doctors is particularly unfortunate with regard to patients with OUD. The reaction of one doctor, when asked about the sparse availability of buprenorphine treatment, was a flat comment that “Most doctors don’t want to treat OUD or SUD patients.” A Statnews editorial on this topic concludes that a pervasive problem is that a) many doctors do not see addiction “as a brain disorder requiring treatment, but as a personal failing,” and b) “some physicians believe that medication-assisted therapy is little more than switching one addiction for another.”+
Even among those doctors who are willing to treat OUD patients, the problem is compounded by the fact that even now—in the midst of an opiate crisis—treating addicted patients with medications such as buprenorphine is highly regulated, requiring strict state and federal registration. To be permitted to prescribe, regulations require that doctors take eight hours of training (for NPs and PAs the requirement is 24 hours of training), after which they are required to register for a DEA waiver.
A further deterrent to the propagation of buprenorphine treatment is the inspection of office records by DEA agents (see within link, “What to Expect When the DEA Comes to Your Office”). An independent-minded physician—who may already be unenthusiastic about treating “addicts”—is unlikely to readily tolerate this sort of heavy-handed government interference in his or her practice. As it is, at present, despite the generally acknowledged opiate crisis, fewer than 7% of US physicians currently have DEA waivers for the prescription of one of the safest and most effective methods of treatment for opiate addiction.
Ties that Bind
This means that while the opiate crisis is raging, the hands of the practitioners who ought to be on the front lines of the fight are bound—both self-bound and bound by regulations. Doctors Kevin Fiscella and Sarah Wakeman ask in another StatNews editorial, “Would deregulation work?” They go on to note that “after France instituted this approach in 1995, deaths from opioid overdoses dropped nearly 80 percent.” Until attitudes among caregivers become more advanced, and until a proper deregulation movement for the prescription of buprenorphine gains national attention, attempts to stem the crisis are little more than a grand display of running in place.
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