Pharmacotherapy, often referred to as medically assisted treatment, has a strong evidence base in the treatment of opioid330, 331 and alcohol dependence.332 Research has consistently demonstrated that methadone, buprenorphine and naltrexone are effective in reducing the craving for opioids and alcohol, increasing retention in substance use treatment, reducing alcohol and opioid use, increasing alcohol-free and opioid-free days, and reducing mortality and HIV risk.333 Currently, there are four medications that have been approved by the HHS Food and Drug Administration (FDA) for use in treating alcohol dependence: disulfiram (Antabuse®), oral naltrexone (Revia®), acamprosate (Campral®), and an intramuscular once-a-month naltrexone injection (Vivitrol®). In the 2006 COMBINE study, the largest RCT of the effectiveness of pharmacotherapy for alcohol addiction,334 eight groups of recently diagnosed patients with alcohol dependence received medical management with 16 weeks of naltrexone or acamprosate, both, and/or two placebos, with or without a combined behavioral intervention (CBI). A ninth group received CBI only (no pills). Patients who received medical management with naltrexone, CBI, or both fared better in drinking outcomes, whereas acamprosate showed no evidence of efficacy with or without CBI. No combination produced better efficacy than naltrexone or CBI alone in the presence of medical management. Naltrexone with medical management could be delivered in health care settings, thus serving alcohol-dependent patients who might otherwise not receive treatment. Other research has shown that naltrexone is effective in reducing alcohol consumption, relapse, and craving among alcohol-dependent patients who are being treated in ambulatory primary care settings.335 A recent randomized clinical trial suggests that providing intensive care and pharmacotherapy in a primary care setting proffers better clinical outcomes for patients with alcohol use disorders than those obtained in specialty SUD care.336
Even though pharmacotherapy for opioid and alcohol dependence may have a strong evidence base, its uptake in primary care has been slow.333, 336, 337, 338, 339, 340, 341, 342, 343, 344 Pharmacotherapy for opioid dependence with methadone is permitted only in accredited specialty substance use treatment programs.345 The Drug Addiction Treatment Act of 2000 (DATA 2000) allows qualified physicians to dispense or prescribe specifically approved Schedule III, IV, and V narcotic medications for the treatment of opioid addiction in primary care, FQHCs, and specialty practices such as pain management clinics. In addition, DATA 2000 reduces the regulatory burden on physicians who choose to practice opioid addiction therapy by permitting qualified physicians to apply for and receive waivers of the special registration requirements defined in the Controlled Substances Act.346, 347, 348 Despite the availability of pharmacotherapies for treating alcohol and opioid addiction by primary care physicians, few PCPs prescribe these medications.339 Only 15 percent of FQHCs that responded to a survey by NACHC had physicians who prescribed buprenorphine to treat opioid dependence. The NACHC survey also found that 43 percent of the FQHCs were interested in training to provide pharmacotherapy for their patients with SUDs, but more than 70 percent of those FQHCs thought that only 1-2 physicians would be interested in free training.349
In this project, although only one of the four FQHC sites that were studied offered MAT for alcohol dependence, all four sites indicated interest in offering pharmacotherapy to participating clinics. the FQHC leadership and physicians expressed strong interest in building capacity, but training resources are needed. Some sites indicated that training alone would be insufficient and that strategies for obtaining and maintaining providers who were willing to prescribe medications needed to be identified. Moreover, more work needs to be done to educate both providers and patients about MAT's effectiveness and to overcome stigma about its use.