Dr. Audrey Provenzano explores the difficulties in treating opioid use disorder in The New England Journal of Medicine‘s “Caring for Ms. L.” Provenzano has already developed rapport with Ms. L when one day the patient admits to her doctor that she had “taken a few of the oxycodone pills prescribed for her husband… [a]nd like a swimmer pulled into the undertow, she was dragged back into the cold, dark brine of addiction.” Ms. L is eager to try a treatment called buprenorphine but Provenzano doesn’t have the special license or training to prescribe the medication. Ms. L expresses disappointment at needing to establish care with a different provider. She trusts her doctor and doesn’t want to tell anyone else about her addiction.
Provenzano confesses that “the reason I didn’t have a waiver to prescribe buprenorphine was that I didn’t want one…. Every Friday I left the office utterly depleted, devoid of the energy or motivation it would take to spend a weekend clicking through the required online training.” She admits that more than anything, she avoids the training because she “did not want to deal with patients who needed it.” Provenzano had witnessed the toll addiction can take on a patient’s relationships and life and “[a]lready overwhelmed, I did not want to take on patients with needs that I did not know how to meet.”
Most primary care physicians can relate to Provenzano. There is already an alarming amount of burnout that exists among today’s physicians; the thought of adding another degree of complexity seems untenable to most, especially if it seems the therapeutic need is insurmountable.
Provenzano notes, though, that when Ms. L returns to her for diabetes treatment after seeing a colleague for the buprenorphine “a space had opened between us.” Ms. L doesn’t return for follow up and it is a year later that Provenzano learns that Ms. L died of an overdose. Provenzano experiences a “profound sadness” for Ms. L’s family, though “it was the shame that kept me awake.” She can’t help thinking that, given the strong patient-physician relationship they had previously developed, if Provenzano had treated Ms. L herself things might have turned out differently.
Provenzano goes on to get buprenorphine training and experiences both the therapeutic and complex social aspects of managing patients with opioid use disorder. She advocates for moving beyond just the training needed to prescribe medications for this chronic disease, but also urges us to “recognize, name, and talk about the social issues that must be addressed” and establish “team-based behavioral health and social work resources.”
Provenzano eventually finds treating patients with opioid use disorder “the most meaningful part of my practice.” She ultimately experiences great satisfaction in providing some normalcy to patients who are “roiled by overdose and estrangement.” Have you experienced the same?
Writing Prompt: As a patient, can you understand or appreciate Dr. Provenzano’s hesitation at first? If you’re a physician, have you experienced a similar hesitation? If you’ve suffered from addiction, what has been the most therapeutic intervention you’ve received? Think about an experience with addiction, either on a personal level or with a patient, that was particularly difficult. Then consider an interaction or moment that was a breakthrough. Write for 10 minutes.