Dear Editor:

The October/December 2019 volume of the Journal of Addictions Nursing contains an article by Dr. Tonja M. Padgett titled "The Advantages and Disadvantages of Medication-Assisted Treatment in Primary Care Offices." Although I wish to thank the author for continuing the active national dialogue on facilitators and barriers to the expansion of treatment for opioid use disorder (OUD), I am concerned that some misrepresentations in the article could create treatment barriers. As an Advanced Practice Registered Nurse (APRN) clinician and educator who has worked in OUD treatment for 19 years, I am acutely aware of the many treatment barriers that result in a considerable treatment gap: In 2018, among the estimated 2.028 million U.S. citizens with OUD, only 400,000 received specialty treatment.1

In her article, Dr. Padgett states: "Federal law mandates that therapy is available and provided to people receiving MAT." Although this is true in federally licensed opiate treatment programs, it is not true for so-called medication-assisted treatment (MAT) provided in primary care offices or other office-based settings. The author notes that the greatest potential disadvantage to receiving care is the "required psychotherapy treatment with MAT" and also notes that "federal law mandates that therapy is available and provided [underline mine] to people receiving MAT." Again, the provision of therapy with MAT is required only in federally licensed opiate treatment programs (often called "methadone clinics"), but not in office-based settings where naltrexone and buprenorphine can be provided. In fact, the federal DATA 2000 law, which allows office-based medication treatment for OUD, states that providers "must attest that they have the capacity to refer [underline mine] addiction treatment patients for appropriate counseling." It does not specify the type of counseling providers must offer referrals to, and it does not specify that the patient must accept the referral or actually engage in the counseling to receive MAT. To suggest that provision of counseling is required for office-based MAT can create treatment barriers, because misinformed providers with good treatment intentions may choose not to provide known effective medications for OUD if they are unable to provide therapy.

I acknowledge that the author may be referring to state-specific regulations or to Medicaid policy in some states requiring counseling to be part of treatment if office-based MAT is reimbursed. If this is Dr. Padgett's reference, it is far from clear. Although the laudable intention of such state-specific policies may be to always employ the most thorough treatment possible, it is important to note that providing some effective evidence-based treatment-such as buprenorphine alone-is preferable to providing none. Last year, the National Academies of Science Engineering and Medicine published a report titled "Medications for Opioid Use Disorder Save Lives." After extensively reviewing literature on the benefits of counseling in the MAT environment, a main conclusion of the report was: "Lack of availability of behavioral interventions is not a sufficient justification to withhold medications to treat OUD."2

Some offices do not have the capacity to provide counseling, although it would be wonderful if all did. In addition, some patients cannot or will not access all aspects of recommended care. Required counseling must not create another barrier to effective MAT provision. We must spread the news that, although the office-based MAT provider must have the capacity to refer patients to counseling, nonetheless, counseling is not a federal requirement to receive office-based MAT treatment.

Respectfully Submitted,

Matthew Tierney, ANP, PMHNP, CARN-AP, FAAN

UCSF School of Nursing, UCSF Office of Population Health

1 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2015-2018. [Context Link]

2 National Academies of Sciences, Engineering, and Medicine 2019. Medications for Opioid Use Disorder Save Lives. Washington, DC: The National Academies Press. https://doi.org/10.17226/25310. [Context Link]