How should I handle patients who are stable on MAT (buprenorphine) but still using one or more illicit substances, i.e. cocaine, methamphetamines, MDMA, nonprescribed benzo?
It should be a goal to reduce 'terminations' from care at all levels whether inpatient, outpatient, with or without MAT. It has been my practice to keep patients on MAT/buprenorphine even with continued use of other illicit drugs as long as there is no ongoing symptomatic safety concerns such as over sedation. For example, if someone is on a prescribed benzo from another physician but does not present as drowsy/impaired I will continue the buprenorphine. Stimulant use such as cocaine, methamphetamines, or nonmedical use of a prescription stimulant has associated risk but does not increase the risk of buprenorphine side effects. Continued use of other illicit substances needs to be addressed as part of a comprehensive treatment plan but should not lead to MAT discontinuation in someone otherwise free from opioid use. If the MAT is discontinued due to other drug use and the patient relapses to full agonist opiate use (heroin, fentanyl, oxy, etc.) the risk of overdose and death is substantial. In addition, there is no consistent data that continued use of MAT in the face of other illicit drug use contributes to diversion.
How can I get more of my PCP colleagues interested in providing MAT?
Increasing MAT access across the country will require significant participation from primary care fields of medicine (Family Medicine, Internal Medicine, OB/GYN, Pediatrics). There is often stigma associated when working with patients diagnosed with substance use disorders especially when providing MAT. First, be an example of quality practice providing evidence-based medical care to SUD patients. Second, offer your expertise to your colleagues on treating SUD patients. Third, encourage interested clinicians to review the excellent evidence-based resources provided for free on PCSSNow.org, NIDA (drugabuse.gov), and SAMHSA (SAMHSA.gov). Fourth, offer to mentor your colleagues through the process of obtaining the DATA Waiver and how to integrate the MAT practice into the daily workflow. Once clinicians see a successful integration working well, many of the barriers to becoming a MAT provider can be easily overcome.
