This piece was originally posted on the STFM blog. Click here for the original posting. Reprinted here with permission.
A Prince in Crisis
On April 21, at 9:43 a.m., the Carver County Sheriff's Office received a 9-1-1 call requesting that paramedics be sent to Paisley Park. The caller initially told the dispatcher that an unidentified person at the home was unconscious, then moments later said he was dead, and finally identified the person as Prince. The caller was Andrew Kornfeld, son of Howard Kornfeld, a California addiction medicine specialist. Andrew had flown to Minneapolis with buprenorphine that morning to devise a treatment plan for opioid addiction. Emergency responders tried to revive the talented musician, but later pronounced him dead at 10:07 a.m.
On April 20th, the day before, Prince’s representatives contacted Dr. Howard Kornfeld, a California addiction medicine specialist, who agreed to see Prince later that week. Dr. Michael Schulenberg, a family physician in Minneapolis, saw Prince on April 7 and April 20 apparently for opioid withdrawal. However, Dr. Schulenberg is not a waivered physician and thus could not prescribe buprenorphine. If he had, perhaps Prince would now be recovering in a comfortable treatment center in California receiving state-of-the-art medical care. He would likely be receiving buprenorphine treatment to prevent opioid withdrawals. Recent autopsy results show that Prince died from an accidental overdose of Fentanyl.
Prince Rogers Nelson, a "master architect of funk, rock, R&B, and pop”, was 57 years old when he died and leaves behind a massive catalogue of music and a legacy of showmanship and flair. He was an extraordinary individual with immense talent and energy but all confined within the same physical limitations you and I have: a human body. Despite his magnificent gifts, Prince had a very real human problem: opioid dependence. Many people might wonder what might have happened if Prince could have attended that medical appointment on April 21st in Minneapolis or what might have happened if he could have met Dr. Kornfeld in California and started opioid treatment.
The Value of a Family Doc
Here’s another question, though: what if Prince had a waivered family physician who knew him and his body and could have started buprenorphine treatment months, even years, before April 21st, 2016? The conversation with his family physician might have gone something like this:
Doctor: "Mr. Nelson, it’s good to see you. I want to ask you a few questions about your health that I ask all patients during an annual visit. Is that OK with you?”
Prince: "Sure, that’d be fine.”
Doctor: "Mr. Nelson, do you use any tobacco products?”
Doctor: "How many times in the last 12 months have you had 5 or more drinks in one day?”
Prince: "I don’t drink alcohol, doctor.”
Doctor: "How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”
Prince: "Well, doctor, I don’t do illegal drugs but I think I’m using my painkillers too much.”
Doctor: "OK. Let’s talk more about that. Perhaps I can help.”
The data is clear about two things when it comes to opioids: one, it’s a growing problem in virtually every state; and two, prevention and treatment work. While opioids have been used for decades to treat chronic pain, rates of prescription opioid abuse have increased in recent years. Get ready for some big numbers. Treatment admissions for primary abuse of prescription pain relievers surged from 18,300 in 1998 to 113,506 in 2008. The number of unintentional overdose deaths from prescription pain relievers has quadrupled in the U.S. since 1999. Even though hundreds of thousands of patients misuse prescription opioids, only 3 percent of primary care physicians offer them treatment.
Addiction to opioids can successfully be treated with medication-assisted treatment (MAT) which is a combination of medication (buprenorphine, methadone) and behavioral health services. Buprenorphine, a partial agonist, is prescribed in primary care settings to help suppress withdrawal symptoms, reduce cravings, and induce tolerance to protect against overdose. To prescribe buprenorphine you must meet certain requirements, complete eight hours of training, and then apply for a waiver. Having at least two waivered physicians to prescribe buprenorphine is becoming a recognized best practice for primary care clinics using MAT.
Barriers to Treatment
Here’s another gigantic number: almost 30 million persons have no access to a waivered primary care physician. What’s getting in the way? Some barriers include lack of physician training, stigma of addiction, bias against MAT, policy and regulatory issues, and financing. Education and training can easily help overcome the first three barriers; however, we need more institutions to support and offer buprenorphine training. Current state and federal policies cap the number of patients physicians can treat with buprenorphine, deny prescription rights to nurse practitioners and physician assistants, and make it difficult for providers to communicate about a patient’s care. The U.S. Department of Health and Human Services is reviewing several policies and considering changes which is very encouraging.
Opioid addiction is not going away any time soon. The next generation of family physicians will be at the front line of this battle and will need the knowledge and skills (and prescription rights!) to effectively help patients. They will need to know how to screen for opioid misuse and how to counsel their patients. As the STFM Addition Group, we recommend that future curriculum include, at a minimum, training in the following areas: SBIRT, Motivational Interviewing, and an introduction to addiction medicine and buprenorphine treatment. We encourage all family medicine training programs to review their substance use curriculum and consider requiring residents to become waivered.
In 1990 Prince wrote "Thieves in the Temple” a song about rejection and deception. "I feel like I’m looking for my soul, like a poor man looking for gold. There are thieves in the temple tonight”. We will never know how Prince might have responded to a waivered family physician’s invitation for opioid treatment. Undoubtedly he was struggling with real addiction and should have received help sooner. As the rest of the nation grapples with the epidemic of opioid addiction, buprenorphine treatment remains underused. Physicians can keep the "thieves” of misuse and addiction out of people’s lives using effective, state-of-the-art treatment.