Response to the Opioid Crisis is Hampered by Physician Workforce Shortages

Abstract

The US is experiencing an unprecedented opioid crisis, with a record 81,000 opioid-involved overdose deaths in the past year. Addressing the opioid crisis will require a substantial scale-up of access to effective treatment for opioid use disorder. Currently, only 18% of individuals with opioid use disorder receive evidence-based treatment in a given year. While health systems and public health departments are working to implement innovative strategies for engaging people with opioid use disorder into treatment, these efforts are hindered by widespread shortages of addiction treatment providers. Using a case study from the largest municipal hospital system in the US, the authors describe the effects of a workforce shortage on health system responses to the opioid crisis. Solving this national problem will require a multi-pronged approach, including federal programs focused on growing and diversifying the pipeline of addiction providers, medical education initiatives spanning pre-medical through residency training, and enhanced training and mentorship to increase the capacity of allied clinicians to treat opioid use disorder. Workforce development should be combined with structural reforms for integrating addiction treatment into mainstream medical care, and with new treatment models, including telehealth, that can lower patient barriers to accessing treatment.

Introduction

The US is in the midst of an unprecedented opioid crisis, with over 81,000 opioid-involved overdose deaths in the past year,(1) and an estimated 1.6 to 6 million individuals with a current opioid use disorder.(2, 3) The intersection of the opioid epidemic with the COVID-19 pandemic is driving increases in opioid-related fatalities due to the confluence of fentanyl penetration, widespread stress, financial problems, social isolation, and disruptions to healthcare and mental health services.(4–7) These new challenges are bringing greater attention to the longstanding problem of under-treatment of opioid use disorder.

Opioid use disorder is most effectively treated with medications, some of which can be prescribed in primary care and other non-specialty treatment settings, thus allowing for integrated care models. Yet only 18% of individuals with opioid use disorder are receiving first line evidence-based, life-saving treatment with medications(8, 3); a proportion that has remained stable for the past decade, even while overdose deaths have markedly increased. This deficit reflects an addiction workforce shortage that will require significant national and local interventions.

Confronted with persistent opioid use disorder treatment gaps, health systems and public health departments are looking for new ways of engaging and retaining patients in care.(10, 11) There is increased funding available to do so, including the federal Substance Abuse and Mental Health Services Administration (SAMHSA) State Opioid Response Grants ($930 million), the National Institutes of Health Helping to End Addiction Long-term (HEAL) Initiative ($945 million), new Health Resources and Services Administration (HRSA) programs to expand access to opioid use disorder treatment in primary care settings (including in rural and underserved areas), and numerous state and municipal programs. New strategies that have been implemented or expanded in recent years include medication initiation in emergency departments;(12) peer navigation to link patients to treatment following nonfatal overdose;(13) and addiction consult services for hospitalized patients.(14)

While these initiatives hold promise, their impact has been impeded by addiction workforce shortages. This presents a major roadblock to efforts to rapidly expand opioid use disorder treatment and reduce opioid-related overdose deaths. We describe the scope of the addictions workforce problem, and present a case study to illustrate how the workforce shortage constrains the ability of health systems to address the treatment gap. We then identify the historical roots of this workforce shortage and summarize current initiatives and recommendations to ameliorate its impact on the response to the opioid crisis.

Scope of the problem nationally

While the addiction treatment workforce spans many fields of training, (including counselors, social workers, psychologists, nurses, and peer educators, among others), the workforce shortage is particularly acute with respect to physicians. Although many types of medical and behavioral health providers have important roles to contribute, because physicians are particularly integral to expanding access to medications for opioid use disorder, and have not historically been employed in addiction treatment settings, they are the primary focus of this paper.

Addiction became a recognized physician specialty eligible for board certification only in 1991. According to the Association of American Medical Colleges, fewer than 2,500 physicians nationwide are certified in addiction medicine, and only approximately 2,000 are certified in addiction psychiatry.(15) By contrast, there are 22,500 practicing cardiologists in the US; nearly five times the number of addiction physicians.(16) With an estimated 2 to 6 million Americans with opioid use disorder, this leaves approximately one addiction physician for every 350 to 1,300 individuals in need of treatment. In addition to being insufficient in number, the addiction physician workforce does not reflect the racial and ethnic diversity of the populations impacted by opioid use disorder. A majority of practicing addiction psychiatrists are White, and in 2018 under-represented minorities made up less than 0.1% of the pool of addiction medicine and psychiatry fellows.(17) The lack of diversity among providers can present a barrier to improving access, initiation, and retention in treatment for Black and Latinx patients, who may be more likely to enter treatment and to have better treatment outcomes when they receive care from providers who have a shared experience and understanding of structural racism and related social determinants of health.(17–19)

While there have been regional increases in opioid use disorder treatment over the past decade, primarily through modest growth in buprenorphine prescribing,(20) the increase has not kept pace with the growth in need.(19, 21) Treatment shortages are particularly acute in rural areas: nearly 60% of rural-dwelling Americans live in a county without a single buprenorphine-waivered provider and 40% of rural counties have no outpatient addiction treatment facilities that accept Medicaid.(23) There are also racial and economic disparities in access to opioid use disorder treatment, with buprenorphine prescribing primarily benefiting White and higher-income populations.(24–26) Most buprenorphine treatment visits are covered by private insurance or paid out-of-pocket, which severely restricts access to lower income groups. Black Americans have significantly lower odds of receiving buprenorphine than Whites, despite evidence that the prevalence of opioid misuse is similar.(26–28)

Case Study: How the addictions workforce shortage affects an innovative program to increase opioid use disorder treatment: Consult for Addiction Treatment and Care in Hospitals (CATCH)

In response to the opioid overdose crisis in New York City, the NYC Mayor’s Office launched, in 2017, the ambitious HealingNYC initiative, which commits $60 million each year to programs aimed at reducing opioid overdose death.(29) HealingNYC leverages the resources of the City’s public hospital system, (NYC Health + Hospitals [H+H]), and the NYC Department of Health and Mental Hygiene to increase access to opioid use disorder treatment. A key component is the introduction of addiction consult services in the public hospital system, through a new program called Consult for Addiction Treatment and Care in Hospitals (CATCH).

In keeping with the typical organization of inpatient subspecialty care, addiction consult services provide expert evaluation, diagnosis and treatment for substance use disorders of patients who are hospitalized, regardless of their admitting diagnosis. A key component is medication initiation while patients are hospitalized, and linkage to ongoing pharmacotherapy as part of a customized discharge plan. Addiction consult services show promise for improving outcomes in hospitalized patients with opioid use disorder.(30–34) In an ongoing pragmatic trial, we are examining the effectiveness of CATCH as the program rolls out in the 6 largest acute care hospitals of the H+H system.(35)

CATCH teams consist of a medical provider, a social worker or addiction counselor, and a peer counselor; each hospital has 3 CATCH teams. Funding and administrative structures were in place to begin hiring in late 2017, but a lack of qualified physician and nurse practitioner applicants delayed the start date at some hospitals by a full 6 months. While the program was successfully initiated at all 6 hospitals, only 2 of them were fully staffed with CATCH medical providers on their start date. The need is substantial: CATCH teams are consulted on over 500 patients per month, but still reach only about half of the patients who are admitted with a documented history of substance use disorder.

A related barrier to the CATCH program’s implementation and effectiveness is a shortage of office-based medical providers in the community who can continue treatment for patients started on medication while hospitalized. H+H has worked to develop a primary care workforce that can deliver addiction care in the context of regular medical services, but experience and comfort levels have been slower than the moment demands. While the system now has primary care addiction treatment available at all 11 acute care facilities, and in many of its outpatient clinics, it remains challenging to arrange treatment post-discharge. The CATCH program thus illustrates how the impact of increased funding and innovative programmatic responses to the opioid crisis can be compromised by addiction workforce shortages that threaten the effectiveness of even well-resourced, targeted, and thoughtfully implemented programs.

How did we get here?

Regulatory constraints on medications for opioid use disorder treatment

The U.S. has a long history of restricting access to medication for opioid use disorder treatment. Dating back to 100 years ago when tens of thousands of physicians were indicted for maintaining opioid-addicted patients on morphine, law enforcement has dramatically constrained physician treatment of patients with opioid use disorder. When the first evidence-based treatment for opioid use disorder was introduced in 1973, in the form of methadone maintenance treatment, it was relegated to highly regulated opioid treatment programs. Today, methadone remains the most regulated medication in the US.(36) When buprenorphine received approval for the treatment of opioid use disorder in 2002, it was with the caveat that physicians complete 8 hours of dedicated training and receive a special ‘X-waiver’ from the DEA allowing them to prescribe, while placing caps on the number of patients they are able to treat. Nurse practitioners and physician assistants were prohibited from prescribing buprenorphine until 2016, and can now do so only after completing 24 hours of training. No such restrictions exist on prescribing other opioids, including more dangerous medications such as oxycodone and fentanyl. Currently only 5% of all medical providers, (10% of primary care providers), are waivered to prescribe buprenorphine, and regulations continue to prohibit the prescribing of methadone (except for pain) in medical settings.(37–39) With a legacy of separating opioid use disorder treatment from mainstream medical care, the US has been unable to fully leverage existing health care systems to respond rapidly and effectively to the current opioid crisis.

Medical education

The average medical school curriculum dedicates only a few hours-- out of four years of training-- to addiction.(40) Barely half of the approximately 10,000 residency programs nationwide require curricular content regarding addiction prevention and treatment, and in many of these programs, addiction content is only 4–12 hours over several years of training.(40, 41) With historically limited curricular training, the medical faculty and supervising physicians of today’s trainees are ill-equipped for overseeing the scale and complexity of care necessary for appropriately responding to today’s opioid epidemic.

Medical training generally involves both didactic and clinical education. However, the bulk of skill acquisition occurs under an apprenticeship model, and across a variety of clinical settings.(42) While there is no shortage of patients with substance use disorders who cycle through clinical training environments, few of them are receiving evidence-based treatment under a long-term outpatient care model for the substance use disorder as a primary diagnosis. Trainees who are never exposed to successful and meaningful treatment for substance use disorders do not gain the required clinical knowledge about effective options for their management. Among recent family medicine graduates, for example, just 10% reported being trained to prescribe buprenorphine, and only 7% had ever prescribed it.(43) Lacking experience and role models, the idea of a career in addiction treatment is unlikely to ever cross the mind of a young physician.

Stigma

Because few medical providers are exposed to effective opioid use disorder treatment and successful patient outcomes, there is a misperception that this condition cannot be treated effectively. This sets up a confrontational situation that pits provider against patient, (especially in high acuity settings such as hospitals and emergency departments), with some providers considering these patients an unnecessary burden, and labeling them as “drug seeking” or “addicts that will be back again.”(44) Despite overwhelming evidence of the effectiveness of medications for opioid use disorder, many providers, patients, and policymakers still hold views that it is “just replacing one drug for another”(45) and that total abstinence (including from prescribed medication) is the only outcome that matters.(15, 46) These misperceptions can lead providers to blame the patient or to incorrectly believe that treatment is ineffective, while ignoring the social determinants of health and structural inequities (such as housing, food insecurity, criminal justice involvement, violence, etc.), that make treatment challenging.(19) These persistent sources of stigma likely intersect with other biases in care settings treating a disproportionate number of patients who are people of color or economically deprived. Inadequate reimbursement, particularly from public insurers, may be a further disincentive for attracting providers to the field.(47, 48) The end result is less treatment for patients, less experience for providers, lack of mentorship, and persistent stigmatizing attitudes. As a result of the historical neglect of opioid use disorder treatment, we are left with an antiquated addiction treatment system that is not attractive to providers or meeting the needs of patients.

Current efforts and potential solutions to grow the addictions workforce

As detailed below, strategies that could effectively expand the addictions workforce include federal programs, medical education initiatives and continuing medical education (Table 1). At the state and local level, while some of the billions in settlement dollars gained in lawsuits against opioid manufacturers could potentially be allocated to workforce development, it has not been prioritized.(49, 50)

Table 1.

Initiatives with potential to expand the addiction provider workforce

Program Name	Target	Status	Focus on Opioid Use Disorder Treatment
Federal Programs
Opioid Workforce Act of 2021	Medical residents	Pending legislation	Yes
Behavioral Health Workforce Education and Training (BHWET) program	Graduate students, underserved areas	Active	No
HRSA Title VII pipeline programs	Medical students, underserved areas	Active	No
Minority Fellowship Program	Behavioral health professionals (Master’s and Doctoral graduates)	Active	No
Medical Training Initiatives
Summer Health Professions Education Program	Undergraduates, diverse backgrounds	Active	No
Medical school X-waiver training	Medical students	Active in limited number of schools	Yes
Resident addiction medicine clinics	Medical residents	Active in limited number of residency programs	Yes
Clinical addiction training programs to increase workforce diversity (REACH program)	Medical students and fellows	Active in one school, limited capacity	No
Continuing Medical Education
Provider Clinical Support System (PCSS)	Practicing medical providers	Active	Yes
Opioid Response Network (ORN)	Community programs and providers	Active	Yes
Extension for Community and Healthcare Outcomes (ECHO) program	Practicing medical providers	Active	Yes

Federal programs for workforce development

Federal lawmakers and agencies have begun to respond to the addiction workforce shortage. Bipartisan legislation, the Opioid Workforce Act of 2021, proposes to add 1,000 graduate medical education (GME) positions over the next five years in hospitals that have, or are establishing, accredited residency programs in addiction medicine, addiction psychiatry, and/or pain medicine. HRSA has started offering a federal loan repayment program specifically targeting health care providers who will work in underserved areas to expand access to addiction treatment. In June 2020, HRSA also issued one round of grant awards ($20 million in total) to support addiction medicine fellowship programs.

While these new federal programs are a step in the right direction, additional large-scale, timely, and sustained action is needed. Existing programs that were designed to meet the public health needs of rural and underserved areas could be utilized for this goal, but will need to be significantly and rapidly expanded to meet the need for treatment. An example is the Graduate Psychology Education, Opioid Workforce Enhancement Program, Behavioral Health Workforce Education and Training (BHWET) program, which works with members of local communities to provide interdisciplinary treatment for mental health and substance use disorders. The HRSA Title VII pipeline programs could be similarly directed to include an explicit focus on increasing evidence-based opioid use disorder treatment. These programs include the Health Career Opportunity Program (HCOP) and Centers of Excellence (COE), which help recruit and retain minority and disadvantaged students who are more likely to practice in rural and underserved areas. Similarly, programs such as the SAMHSA Minority Fellowship Program (MFP) could be expanded to more explicitly focus on medical providers who can prescribe medications for opioid use disorder, including physicians and nurse practitioners. By cultivating interest and commitment to providing opioid use disorder treatment among a larger and more diverse group of providers, infusing additional resources into these programs could offer a sustainable pipeline for addressing the workforce shortage in the most underserved areas, and potentially improve racial equity.

Medical Education Initiatives

Universities have an important role to play in developing the robust pipeline that is needed to address rural and underserved workforce challenges, by recruiting individuals more likely to practice in these settings. For example, the Robert Wood Johnson Foundation has invested in the Summer Health Professions Education Program (formerly the Minority Medical Education Program), a successful 30-year model program that has served over 30,000 college students.(51) Data show that it has significantly increased the number of diverse candidates applying, matriculating and graduating from medical and dental school. The combination of academic support, mentoring, and career development contributes to positive workforce outcomes.

While undergraduate training is necessary for building a robust and sustainable addictions workforce, it will be years before these trainees are able to provide care. Medical school and residency training programs have the potential to contribute more immediately to addressing the opioid crisis. Pre-clinical medical education and training needs to go beyond curriculum change to require practice-based knowledge of basic addiction treatment, including medication for opioid use disorder, consistent with expectations for fundamental skills in other areas of medicine. For example, the state of Massachusetts organized four of the larger medical schools to collaborate on a shared curriculum to fulfill state-level buprenorphine DEA X-waiver training requirements for all medical students prior to graduation.(52, 53) In New York, the public H+H system has residents rotate through primary care buprenorphine clinics. Modeled on a successful program developed at Yale,(54) the goals are to improve knowledge acquisition for both residents and attending physicians, expand treatment availability, and spur a larger culture change. This model has positive impacts on multiple levels for trainees and patients alike, but has been slow to implement for the very same reason it is needed; a lack of strong addiction trained faculty to serve as mentors.

Medical education programs on addictions could also be utilized to enhance diversity, equity, and inclusion in addiction treatment. One example is a 5-year training grant funded by SAMHSA, the ‘Recognizing and Eliminating disparities in Addiction through Culturally informed Healthcare (REACH)’ Program, which offers didactic teaching and mentorship in addiction treatment for under-represented minority medical students, residents, and advanced health professional students.(17, 55) The expansion of REACH and similar models, along with stable funding, could have a meaningful impact on both the size and the diversity of the addiction physician workforce.

Transforming current medical providers into an effective addiction treatment workforce

A particularly encouraging trend flows from the 2016 passage of the Comprehensive Addiction and Recovery Act (CARA), enabling nurse practitioners (NPs) and physician assistants (PAs) to obtain buprenorphine waivers. As a result, from 2016 to 2019 the number of waivered clinicians per 100,000 population in rural areas increased by 111 percent.(22) NPs and PAs accounted for more than half of this increase. In rural areas, broad scope-of-practice regulations (giving NPs and PAs greater prescribing authority) were further associated with twice as many waivered NPs per 100,000 population compared to areas with a restricted scope-of-practice.(22) The rapid growth in the number of waivered NPs and PAs holds promise for scaling up access to these prescribers and extending physician impact in states requiring collaborative agreements.

Waiting for the pipeline to produce independently practicing addiction providers is a long-term solution, but to respond to the current crisis, mentorship and guidance is needed now for practicing providers. A number of programs and models exist to fulfill this need, though they remain underutilized. The SAMHSA-funded Provider Clinical Support System (PCSS) offers high quality training modules, audio lectures, discussion forums, and one-on-one direct expert mentoring, as well as access to free buprenorphine waiver training.(56) The Opioid Response Network (ORN) is another free program founded through SAMHSA to provide technical assistance to programs and providers. The Extension for Community and Healthcare Outcomes (ECHO) program has been effective in increasing buprenorphine prescribers in rural areas,(57) and could be more widely utilized in urban and suburban health systems. For example, H+H now utilizes the ECHO platform to expand the number of buprenorphine providers across their large urban public system. The H+H ECHO has increased the number of providers actually prescribing buprenorphine, assisted in clinical dilemmas, improved self-efficacy, improved knowledge, and, importantly, developed a supportive community to foster system-wide champions.(58)

Recognizing that primary care providers are already overburdened, some health systems have introduced collaborative care models for opioid use disorder treatment that can support generalist practitioners in providing addiction care. A pioneering example is the ‘Massachusetts nurse care manager model’, which places a nurse care manager in primary care clinics to co-manage opioid use disorder with primary care providers.(59) This model reduces the burden on primary care providers, while educating them on buprenorphine treatment and maintaining a high volume of treated patients. The Massachusetts statewide dissemination of this model was met with a 375% increase in buprenorphine-waivered physicians within three years, and a large increase in the number of patients initiating office-based buprenorphine treatment.(60) The model has been adopted in other areas, but a lack of addiction-trained nurses and payment structures supporting this role have limited its broad dissemination.(61)

Increased integration of opioid use disorder treatment into mental health care could also have a positive impact given high rates of psychiatric comorbidity, especially depression, anxiety, and PTSD, among patients with opioid use disorder. There are nearly 39,000 practicing psychiatrists in the U.S.,(16) yet most do not routinely offer medications for opioid use disorder treatment,(62) reflecting many of the same barriers cited by primary care providers – namely, lack of knowledge and concerns about ‘practice fit’ and attracting undesirable patients.(62, 63) Yet with extensive training in behavioral interventions, along with their ability to treat co-occurring mental health disorders, psychiatrists are uniquely well positioned to provide medication for opioid use disorder.

New practice models and regulatory reforms

The worsening opioid crisis and the greater barriers to treatment access posed by COVID-19 have stimulated new treatment models and calls for regulatory easing. Telehealth has great promise for expanding access to effective treatment, particularly in rural areas.(64, 65) Spurred by COVID-19 and social distancing measures, and facilitated by the temporary relaxation of regulations under the federal emergency order,(66) buprenorphine treatment is now being routinely provided with only a telephone or video visit.(58, 67, 68) Additionally, for patients in methadone maintenance, limitations have been relaxed, allowing for take-home doses of up to 28 days with remote visits.(66) These new treatment models have particular potential for rural patients, who otherwise have to travel for hours to reach the nearest provider, and could ease treatment barriers even for those living in better resourced areas. However, their sustainability relies on continued regulatory easing, which is not guaranteed, and on the availability of addiction treatment providers, who remain in short supply.

In May of 2021, the US Department of Health and Human Services released updated guidance that allows physicians and most nurses to be eligible for an X-waiver DEA number to treat up to 30 patients with buprenorphine, without undergoing additional training.(61, 69) While a step in the right direction, this updated guidance alone will likely prove to be insufficient unless resources are dedicated to expanding pipelines for the addictions workforce, and addressing the structural issues of stigma and poor reimbursement rates that keep providers from entering the field. Currently, even among prescribers who were motivated enough to complete the required training and receive their X-waiver, 1 in 4 has never written a buprenorphine prescription, and only 13% are prescribing near their patient limit.

In summary, the response to the opioid crisis faces two interlinked barriers: first, individuals with opioid use disorder are not receiving evidence-based and lifesaving treatment due to a shortage of providers; and second, the current shortage is making it difficult to educate and mentor future addiction treatment providers. To swiftly ameliorate the opioid crisis, it is imperative that health systems re-train and utilize their existing providers and structures to increase access to opioid use disorder treatment in primary care and mental health settings, and link patients with specialty telehealth services. Particular attention should be placed on improving buprenorphine access in rural, low-income, and racial and ethnic minority populations. Funding structures need to be developed that incentivize the primary care workforce to increase their delivery of office-based buprenorphine treatment, by supporting collaborative care models and growing the number of PAs and NPs qualified as buprenorphine prescribers. Health systems could adapt ECHO and similar learning collaborative models to cultivate local champions, who in turn can encourage and supervise colleagues in providing addictions care as part of routine practice.

Conclusion

For those physicians experienced with addiction medications, opioid use disorder treatment is highly effective, easily integrated with regular medical care, and often professionally rewarding. However, decades of poor decisions and regulatory barriers have led to a dearth of available medical professionals. A growing chorus is calling for changes in federal policies, including increasing access to medication by completely removing X-waiver requirements for buprenorphine prescribing, and easing regulations on methadone.(19, 71–74) While these changes could have some immediate positive impact, the response will be muted if there are not knowledgeable providers who are able and willing to prescribe these potentially lifesaving medications.

Comprehensive strategies for workforce development, spanning classroom and trainee clinical settings, mentoring and continuing education for practicing professionals, and structural reforms for integrating addiction treatment into mainstream primary care and mental health settings, are urgently needed. We recommend the following actions: 1) Increase the pipeline of trainees who are prepared to treat opioid use disorder, particularly in rural and underserved areas, by passing the Opioid Workforce Act, redirecting the HRSA Title VII programs to focus on areas hardest hit by the opioid crisis, investing some of the opioid settlement funds in workforce development, and prioritizing funding for programs that train under-represented minorities; 2) Expand medical trainees’ knowledge by requiring medical schools and ACGME residency programs to include clinical management of opioid use disorder, emphasizing use of medication; and 3) Increase financial and regulatory support for innovative care delivery models in primary care and mental health settings, enhanced reimbursement and bundled payments for collaborative care models, and the expansion of telehealth services.

Highlights.

1. Only 18% of individuals with opioid use disorder receive first line evidence-based treatment with medications such as buprenorphine or methadone, reflecting unmet need nationwide.

2. Addressing the treatment gap requires growing the pipeline and diversity of trainees, and prioritizing rural and underserved areas, through federal and state programs specifically targeting the opioid workforce.

3. Training initiatives need to be paired with structural reforms to support the integration of addiction treatment into mainstream primary care and mental health settings.