Caso de aplicación 3: modo de seguridad SIL3/cat. 4

Though circumstances were different in each example, physicians’ choices to practice addiction medicine in its respective forms and venues arose in response to an identified need either within themselves or within their patient population, agencies, and communities. Dr. Hansen explains that he chose Valley Health because

I felt called to work with a patient population that probably doesn’t get healthcare otherwise because not many private physicians want to see patients with Medicaid or patients without insurance and Valley is uniquely set up to be able to handle that population.

Here Dr. Hansen explains that his intentional choice to enter medical practice geared toward the treatment and care of an underserved population grew from his desire to provide care to people whose healthcare access is limited by their inability to pay for it. Dr. Knapp expresses

similar motivations citing the Hippocratic Oath “if you go back to the Hippocratic Oath ... that's who you're supposed to target. That's who you're supposed to help, the needy who have nobody to fight for them,” and references “the plastic surgeons of the world” who are making money providing an in-demand service but are not necessarily upholding the oath to care for “people that legitimately need medical help who are not getting it.”

After entering practice at Valley Health, Dr. Hansen noticed within himself a need for “immediate gratification” in his practice. He explains he wanted to see conditions improve, so he took his dad’s suggestion and decided to get certified to administer Suboxone.

I was seeing these patients come in in a bad way, desperate, despondent, afraid of what their future was going to bring them and to see them respond to the medication and be able to turn their lives around, achieve some sense of normalcy gave me the gratification I was missing.

For Dr. Marshalek, the opportunity in medical school to witness first-hand the drastic improvements patients underwent after receiving MAT “opened my eyes to addiction treatment.” In Dr. Carl “Rolly” Sullivan, Dr. Marshalek had an experienced mentor, a factor the literature identifies as highly influential in medical students’ choice to enter addiction medicine. Working with Dr. Sullivan “solidified my decision to pursue a residency training program in psychiatry,” says Dr. Marshalek adding, “We’re ahead of things; we’re progressive in terms of the amount of exposure to substance use disorders, addiction, psychiatry, and addiction medicine.” Dr. Berry echoes a similar awakening in his last medical school rotation.

Dr. Christiansen’s interest in addiction medicine developed while he was treating a patient with infected endocarditis. The patient, an IV drug user, had been addicted to heroin for over two decades and despite warnings that he could die from the infection and could potentially

be denied future valve replacements if he continued to use, this patient could not stop using. Dr. Christiansen recalls, “I thought, there’s got to be something different with this guy. He’s not suicidal. He doesn’t want to harm himself. He just can’t stop.” When the patient asked Dr. Christiansen for answers as to why he continued to use heroin knowing it would kill him, Dr. Christiansen admits he could not produce an answer for the patient. But, not having the answer compelled Dr. Christiansen “to do a lot of reading and learning about better options for this patient. Is he just destined to be in this situation, imprisoned by this substance he can’t get away from?”

The upsurge in pregnant women with substance use disorder presents a variation on the theme of an inability to quit substance even while knowing continued use will endanger patients’ health or the health and well-being of their children. With the highest rate of babies born with Neonatal Abstinence Syndrome (NAS) in the nation, physicians and residents at Cabell Huntington Hospital had no choice but to respond to the need within the community by providing medical intervention for substance use disorder to pregnant women and their babies and training in the practice of prescribing MAT to their residents. Dr. Cummings states that she was “raised on prescribing” because the demand for medical interventions to reduce the risk of harm to pregnant women and their babies was so great during her residency, learning MAT was a natural and logical component of her training.

What barriers, if any, must doctors overcome to become a MAT prescribing physician? The logistics of setting up an office-based MAT practice and becoming certified to prescribe buprenorphine requires physicians to undergo training through SAMHSA to comply with the DATA 2000 and obtain the DEAX number to prescribe controlled substances. The research indicates these processes are significantly more cumbersome for physicians who

received no exposure to the patient population and no opportunity for education, mentorship, and practice prescribing MAT in medical school or residency training (Olivia et al., 2011; Stӧver, 2011). Physicians’ attitudes toward the practice of prescribing, addiction, and the patients who suffer addiction may present as barriers to prescribing if medical residents are not trained to understand the biological, psychological, social, economic, and spiritual contexts in which addiction manifests (Friedmann et al., 2001).