Dr. Elinore McCance-Katz, the Trump administration’s director of the Substance Abuse and Mental Health Services Administration, helped pioneer opioid addiction treatment with buprenorphine in clinical trials in the 1990s. She also helped create the training for doctors who want to prescribe it. What follows is a condensed interview with her.
Q. How much of your time is spent addressing the opioid epidemic?
A. I probably spend half of my time on it. I also, of course, spend time on serious mental illness issues, and on planning; keeping the organization running; making sure all the various components of what is a large and complicated organization are continuing and getting worked on.
Q. What kinds of doctors are pursuing the training and certification that the federal government requires to prescribe buprenorphine?
A. There’s a lot of psychiatry. There are a significant number of primary care providers, but there are also specialists. There are pediatricians who get the waiver; OB-GYNS who get the waiver; pain specialists who get the waiver. And then, of course, there are addiction specialists who get the waiver — addiction medicine or addiction psychiatry.
Q. Do you think the number of primary care providers who prescribe buprenorphine is growing fast enough?
A. What I will say is that we have a lot of work to do. When we first thought about this treatment, it was really thought about as a way to integrate treatment of opioid use disorders, opioid addiction, into primary care. Because we know that many, many people with opioid problems have other medical problems, and sometimes they have psychiatric problems, too. Psychiatry has had much more uptake on this than has primary care. But the idea was you eliminate the stigma by just having them be another patient in the waiting room. That was the hope.
Q. So why are primary care providers still generally reluctant to provide addiction treatment?
A. In recent years, medical schools have been putting more hours of training on addiction in place. But for probably the majority of physicians practicing now, we had very little to no exposure to it in medical school, or even in residency. If you don’t learn how to treat what is a complex disorder, then you feel uncomfortable taking it on. And because these disorders often involve psychosocial problems, many primary care doctors feel they may not have the resources to fully assist people. I talked to my own primary care provider about it and she said, ‘You know, Ellie, I don’t think I’m the right person.’
Q. So what’s the solution?
A. Most people don’t go into medicine because they want to treat substance use disorders. Some of us do, but most of us don’t. So the way to address that is to bring addiction treatment into the mainstream of medicine. What I mean when I say that is that we have to incorporate the screening and treatment of substance use disorders within medicine and have it be just like any other illness. That way, your medical students are learning about this from the time they enter their undergraduate education. And by the time they graduate and go to residency or to fellowships, it’s just part of what you do — it’s like you don’t think twice about taking somebody’s blood pressure. You just do it. That’s where we need to get to.
Q. There are still a lot of providers who prefer an abstinence-based approach to opioid addiction treatment. How do you look upon abstinence-based treatment at this point?
A. People need to have all the options available to them. They should not be shoehorned or pushed into an abstinence-based program, particularly if they’ve had relapsing disease. They deserve a chance with medication-assisted treatment. Too often, that doesn’t happen in this country. They can choose (abstinence-based treatment) if they want to; there are patients who say that, there definitely are. But I will say to them, ‘Here’s what you just told me about your life and history. I’m going to tell you that based on my history with people who have the kinds of problems you have, you have zero chance of being able to maintain your abstinence. Let us help you.’ You get them stabilized. They don’t stay on that medication forever. Eventually, they may get to the point of abstinence-based care. But what we’re saying is let’s have a logical, methodical approach that meets the medical needs of people.