Subscribe to The Podcast by KevinMD. Catch up on old episodes!

Join Jack McGeachy, an emergency physician and expert in addiction medicine. Discover how doctors possess a hidden superpower when it comes to addiction treatment and how they can effectively address the biological, psychological, and social aspects of substance use disorder. Explore the world of addiction treatment, medications, therapeutic approaches, and the legal considerations doctors should be aware of in this insightful conversation.

Jack McGeachy is an emergency physician and addiction medicine specialist.

He discusses the KevinMD article, “Physicians have a hidden addiction treatment superpower.”

Careers by KevinMD is your gateway to health care success. We connect you with real-time, exclusive resources like job boards, news updates, and salary insights, all tailored for health care professionals. With expertise in uniting top talent and leading employers across the nation’s largest health care hiring network, we’re your partner in shaping health care’s future. Fulfill your health care journey at KevinMD.com/careers.

VISIT SPONSOR → https://kevinmd.com/careers

Discovering disability insurance? Pattern understands your concerns. Over 20,000 doctors trust us for straightforward, affordable coverage. We handle everything from quotes to paperwork. Say goodbye to insurance stress – visit Pattern today at KevinMD.com/pattern.

VISIT SPONSOR → https://kevinmd.com/pattern

SUBSCRIBE TO THE PODCAST → https://kevinmd.com/podcast

RECOMMENDED BY KEVINMD → https://kevinmd.com/recommended

GET CME FOR THIS EPISODE → https://earnc.me/8MgxKK

Powered by CMEfy.

Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Jack McGeachy. He’s an emergency and addiction physician. Today’s KevinMD article is titled “Physicians have a hidden addiction treatment superpower.” Jack, welcome to the show.

Jack McGeachy: Thank you so much, Kevin. I’m really happy to be here today.

Kevin Pho: So let’s start by sharing your story and journey to where you are today.

Jack McGeachy: I didn’t start my career thinking I would treat addiction, but it really found me. I trained in emergency medicine at the University of South Florida, and during my training it was really the peak of the initial opioid epidemic wave. I was repeatedly seeing patients come in suffering from the complications of their addiction, in particular young people with endocarditis and other serious, life-threatening infections from IV drug use. That really motivated me to look into what we could do. At that time, emergency medicine really did not see itself as primarily responding to people with addiction. We would reverse these people with naloxone, watch them in the emergency department and discharge them to the streets. But I found that there was actually a growing movement to bring buprenorphine into the emergency department, and at the time we had no such program at Tampa General. So as a resident I started working on a pathway so that we could identify and treat these folks, start them on buprenorphine and link them up with care in the community. It succeeded beyond our expectations, and participating in that and seeing the difference we could make in a patient’s life was just so gratifying. It was really amazing, and it has led me to learn more.

The biggest takeaway I want to leave the audience with is that you can do this. Physicians are actually very uniquely positioned, as medical professionals, to provide care to patients with addiction. We have a very unique set of skills that lets us address all three of the domains that characterize the disease of addiction.

Kevin Pho: So just before we move on and talk about this in more detail in your KevinMD article, let’s get everyone on the same page. Give us a 30-second summary of what buprenorphine is and how it’s used.

Jack McGeachy: That’s a great question, and I know not everybody is familiar with the medication. Buprenorphine, in a nutshell, is a very effective treatment for opioid use disorder. It is a partial mu agonist, in contrast to full agonists such as morphine, oxycodone, fentanyl and methadone. It binds to the mu receptors but doesn’t fully activate them, and this has two chief benefits. One is that it alleviates the withdrawal of opioid cessation and prevents cravings, and in this way it can very effectively treat opioid use disorder. It’s more than just substituting one dependency for another. These patients derive great benefit from treatment: Once they’re stabilized on buprenorphine, they can start picking up the pieces of their lives and working on their recovery.

And it saves lives. No bones about it, buprenorphine saves lives. It prevents the complications of opioid use, in particular the infections patients can get from injection. It saves them from the legal consequences of seeking out illicit opioids, and in that way it protects them. It’s also protective against overdose: Buprenorphine binds so strongly to the mu receptor that very few opioids can displace it, and in that way it sets the patient’s opioid receptors at a certain ceiling that protects them from overdose. So it’s just a fantastic drug. I think I went over 30 seconds, but I’m just so excited about buprenorphine.

Kevin Pho: All right, and we’re going to talk more about that in your KevinMD article, “Physicians have a hidden addiction treatment superpower.” You mentioned earlier the three parts of this disease, the biological, the psychological and the social domains. As you lead into the article, maybe start there and go into a little more detail.

Jack McGeachy: Certainly. Addiction really is a tripartite disease, and there are three major domains of dysfunction. There’s the one we’re most familiar with as physicians, the biological, which centers on dependency, tolerance, the physical consequences of drug use and the complications thereof. The second is the psychological domain, which refers to the disordered thoughts and beliefs that lead to addictive behaviors. And the third is the social. That’s the one I think people have the hardest time wrapping their heads around, but it is a very broad domain. Good examples would be the isolation we see in people with addiction, their dysfunctional interactions with their friends, family and society at large, and legal issues. It could also include their socioeconomic status and their housing status. So, in brief, to properly treat substance use disorder, you really have to address all three, and as I mentioned in my article, as physicians we’re actually very uniquely suited to do that.

Kevin Pho: Talk about some of the next steps, in terms of how specifically physicians are suited to treat these three domains.

Jack McGeachy: As far as the biological domain goes, we are the masters. There’s really no other medical professional with the unique training and skill set to address the biological aspects, and in that way I feel most physicians are rather comfortable treating that part of the disorder. But we also have the soft skills. Day in and day out, you’re dealing with similar issues in your patients with chronic diseases like diabetes and hypertension. If you just write a prescription for amlodipine, it doesn’t guarantee the patient is going to take it. So we are well versed in addressing these issues, and treating the psychological needs of a patient doesn’t mean you have to learn cognitive behavioral therapy or become a Freudian psychoanalyst. It’s great if you have those skills, and I will say it’s not as difficult as you might think to gain them, but by just applying what you already practice with your other patients with chronic disease, you can really make a difference in these patients’ lives.

One thing I learned personally, as I was on this pathway to becoming an addiction physician, is that patients really value their relationship with their doctor. In that way, you’re providing for their social needs just by being there for them, and also by providing a sense of accountability. That’s really powerful, and it’s really unique, too. In most other treatment programs, an entire cast of characters is caring for the patient, and the patient may not really feel any sense of accountability to any particular one. Patients derive a lot of benefit from having a relationship with that one bedrock person they see on a regular basis and trust.

Kevin Pho: Tell us a story. Give us an example or anecdote from the emergency department setting where you made a difference in these domains, so we can really bring this to life.

Jack McGeachy: As part of our treatment pathway, I interacted with a number of these patients over the years, and I also saw them incidentally on my shifts. I remember one young man in particular who had a very difficult life. He really didn’t have any friends or family, he was homeless, and he would frequently miss doses of his Suboxone at the treatment center, so he’d come into the ED to get dosed. We would talk regularly about his case and express our concerns. I happened to be his doctor one day when he came in to get one of the doses he had missed, and I sat down with him and said, “Hey, I think you’re doing a great job. I know it’s tough, and I’m just happy that instead of giving up, you came back. In the future, I really want you to work on trying to make it to your appointments, but I still think you’re doing a great job.” At the time, I really didn’t think much of it, but I was told the next day by one of the counselors who cared for him that it had made a real impact on him; he had told her so. In that way, I was able to be there for him and provide that for him.

Kevin Pho: Now, you mentioned earlier that you started a buprenorphine program in your emergency department, making a huge difference in a lot of these patients’ lives. How common is it for emergency departments across the country to have programs like that?

Jack McGeachy: It’s a great question. I think we’re really in the heyday of ED-initiated buprenorphine, which is wonderful. It’s an idea that came out of the Northeast and Yale, but it has really filtered down, and in Florida it seems like almost every hospital, even the small ones, has been setting up programs, which is wonderful. A colleague of mine told me about a program in a rural county where they actually have the fire chief come out to the patient’s home, or wherever the patient wants to meet if they have no home, and induce them on buprenorphine after an ED visit, which I think is great. The particulars of the program are going to look different at each hospital, but I think it’s really picking up.

Kevin Pho: And in your case, in Tampa, are patients who are started on buprenorphine in the emergency department then going to a clinic afterward? Do they go to their primary care physicians, who then continue their buprenorphine? What happens in terms of follow-up?

Jack McGeachy: It’s a great question. With our formal program, we have a partnership with local treatment centers, where the patient will follow up and be cared for. But you can see the model working with a private physician as well, and there really are very few barriers in 2023 to a private physician adopting this as part of their practice. That’s really what the goal of my article was, what I was trying to get across: You can do it, absolutely, and it’s well within your skills. I know it’s scary, especially if you didn’t learn much of this in med school or residency and probably haven’t practiced it before. But buprenorphine in particular is a really powerful tool, and unfortunately it’s not used nearly as much as it should be. Even the feds say they were hoping that removing barriers would expand access, but thus far they really haven’t seen it.

Kevin Pho: How about in a primary care setting? Let’s say we have primary care clinicians who are listening to you now and are inspired to take that first step. Tell us the first thing they should do.

Jack McGeachy: After you take some time to familiarize yourself with the basics of prescribing, which shouldn’t take long, since it’s not too complicated from that end, I think the real first step is screening your existing patients, because unfortunately addiction is far more widespread than we currently recognize. It’s not difficult in theory, but in practice it’s hard to implement. Once you rip the Band-Aid off and start the conversation, though, most folks are very amenable to at least listening. Not every patient will be ready for treatment, but if you let them know the opportunity exists, you open up that space for healing.

Kevin Pho: And if one were to begin prescribing buprenorphine, what kind of training is involved?

Jack McGeachy: Great question. Prior to 2023, you needed to get a waiver to prescribe buprenorphine for opioid use disorder. As of 2023, as long as you have an active DEA license and can prescribe Schedule III drugs, you can prescribe buprenorphine for opioid use disorder; no waiver is required anymore. I still think it’s beneficial to take some training, but it is no longer legally required.

Kevin Pho: And when prescribing buprenorphine, what are some things we need to be careful of?

Jack McGeachy: Overall, I want to begin by saying that it is a very safe medication, but there are some things to be mindful of. When you’re starting a patient on buprenorphine and transitioning them from a full agonist opioid, it is possible to precipitate withdrawal, which can be very distressing to the patient but is not physically harmful, and there are strategies to prevent precipitated withdrawal. As far as medical contraindications, there are some reports of hepatitis, or liver injury, in patients who have an underlying liver condition, so it’s good to perform regular screening labs and be on the lookout for signs of hepatitis or liver failure, but that’s relatively rare.

It’s hard to overdose on buprenorphine, because there is a dose ceiling, and for most adults who are already dependent on opioids, that ceiling isn’t enough to cause respiratory depression. However, children who inadvertently take buprenorphine can overdose, so you should counsel your patients to safeguard their medication. There are some case reports of overdose in patients concurrently using benzodiazepines, but in practice that seems relatively uncommon; you really only see it in people who are misusing their medication by injecting it.

Kevin Pho: We’re talking to Jack McGeachy. He’s an emergency and addiction physician. His KevinMD article is titled “Physicians have a hidden addiction treatment superpower.” Jack, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Jack McGeachy: Absolutely. My biggest take-home would be to believe that it’s possible. You can do this. Thankfully, in 2023 there are relatively few legal barriers to treating addiction among your patients. It’s well within your skill set and in your wheelhouse, and the need is there. The need is certainly there. If a physician decides to take it upon themselves to address this chronic disease among their patients, they are doing a great service.

The last thing I would say is that it is so gratifying to treat patients with addiction. You will see the most tremendous improvements in quality of life. You can take a person who is very sick medically and whose life is in shambles, get them into treatment, and their life will do a 180. It’s so gratifying to see that. I encourage all your listeners to learn more, and if anybody is interested in asking me any questions, I’m open to that as well. I’d love to talk further if you’re interested.

Kevin Pho: Jack, thank you so much for sharing your time and insight, and thanks again for coming on the show.

Jack McGeachy: Thank you, Kevin. It was a pleasure.