The End of the X-waiver: Excitement, Apprehension, and Opportunity.

With the passage of the MAT act (Mainstreaming Addiction Treatment) and the MATE Act (Medication Training and Expansion), the Drug Enforcement Agency "X-waiver" program governing the office-based prescription of buprenorphine for opioid use disorder has been immediately eliminated. The move was championed by vocal organizations with a rightful concern about buprenorphine access but was opposed by most physicians. Nonetheless, buprenorphine can now be prescribed like any schedule 3 medication. Studies show that despite rising opioid overdoses, buprenorphine prescription increases have been slow to rise and are particularly absent in rural communities. The elimination of the X-waiver may theoretically improve buprenorphine prescribing rates for opioid use disorder in rural areas, by nurse practitioners and physician assistants, and by resident physicians in teaching programs. It may also help decrease discrimination against individuals with opioid use disorder in postacute-care settings like nursing homes, physical rehabilitation centers, and in prisons and jails. Concerns include the elimination of the only focused opioid use disorder education many physicians receive (X-waiver courses) and a literature base showing that interest, rather than the X-waiver itself, remains the biggest barrier to recruiting more buprenorphine prescribers. Concerns also exist over the harms of precipitated withdrawal when buprenorphine is initiated inappropriately. The change of the elimination of the X-waiver brings about a new opportunity for Family Medicine and its parent organizations to champion the inclusion of opioid use disorder treatment within the chronic disease care models well-known to our integrated care settings.

Barriers to care for perinatal patients with opioid use disorder: family physician perspectives.

BACKGROUND: While barriers to care for pregnant patients with opioid use disorder (OUD) have been described, the experiences and challenges of the physicians providing care to these patients are poorly understood. OBJECTIVES: To describe the experiences of family physicians providing comprehensive care to pregnant people with OUD and the challenges they face in providing such care. METHODS: Qualitative thematic analysis of 17 semistructured interviews conducted from July 2019 to September 2020 with family physicians who possess a Drug Enforcement Administration "X" waiver and provide care to pregnant patients. RESULTS: Seventeen family physicians practicing in the United States who care for pregnant people with OUD were interviewed. They described physician-, patient-, and systems-level barriers to providing and accessing care for this patient population. Of the 12 interrelated themes regarding challenges to delivering and accessing this care, 3 were particularly salient: the pervasive effects of social determinants of health, a lack of adequately trained providers, and social stigma associated with pregnant people with OUD. CONCLUSION: A comprehensive, multilevel, and multidisciplinary approach is necessary to address these barriers and move towards health equity for this vulnerable patient population.

Teaching residents to prescribe buprenorphine for opioid use disorder: Insights from a community-based residency program.

INTRODUCTION: Despite the impact of the opioid overdose crisis on the United States, few physicians are trained to provide treatment with buprenorphine. While research has described some factors contributing to comfort in providing buprenorphine treatment, more research is needed to identify optimal strategies to produce physicians who prescribe this medication. METHODS: A community-based family medicine residency in Massachusetts sought to improve residents' comfort with prescribing buprenorphine by integrating patients treated with buprenorphine directly into resident continuity clinic panels in addition to existing mandatory didactic teaching. RESULTS: The program saw a significant increase in buprenorphine prescribing among residency graduates three years after graduation after integration of patients on buprenorphine into resident continuity panels. CONCLUSION: Efforts to further increase the number of graduates prescribing buprenorphine nationwide should emphasize supervised management of patients treated with buprenorphine during residency.

Liver Disease: Evaluation of Patients With Abnormal Liver Test Results.

The prevalence of abnormal liver test results in the general population is estimated to be between 10% and 20%. The terms liver tests or liver chemistries are recommended to describe more accurately the tests used to assess liver health, instead of the term liver function tests. Defining normal ranges for liver transaminase levels can be challenging. Levels are affected by factors such as body mass index and sex. Elevated transaminase levels are associated with increased risks of liver-related and all-cause mortality. Patient with signs or symptoms of liver disease or abnormal liver test results should be evaluated to determine the etiology. For patients with abnormal liver test results, the initial evaluation should include a review of previous laboratory test results, medical and family histories, substance use, and drugs, including over-the-counter drugs and herbal supplements. Physical examination results often are normal but findings may be consistent with acute disease. Tests should include a complete blood cell count; alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, total bilirubin, and albumin levels; prothrombin time; hepatitis B surface antigen; hepatitis B core antibody; hepatitis C antibody; ferritin and iron levels and transferrin saturation; and right upper quadrant abdominal ultrasonography. Additional tests and imaging should be based on patient-specific risk factors and the pattern of abnormal liver test results.

Liver Disease: Nonalcoholic Fatty Liver Disease.

Nonalcoholic fatty liver disease (NAFLD) describes a spectrum of fatty infiltration, inflammation, and fibrosis of the liver caused by metabolic factors. It is projected to become the leading cause of cirrhosis and need for liver transplantation in the United States. Guidelines from the American Association for the Study of Liver Diseases (AASLD) do not recommend routine screening of patients at high risk of NAFLD. European guidelines recommend testing for certain high-risk patients. Hepatic steatosis and nonalcoholic steatohepatitis (NASH) are difficult to diagnose and often go unrecognized until patients have advanced fibrosis or cirrhosis. Noninvasive methods are used to assess fibrosis, such as fibrosis scores and vibration-controlled transient elastography. Liver biopsy remains the reference standard for NASH diagnosis and fibrosis staging. The mainstays of treatment for NAFLD, NASH, and fibrosis are weight loss and a healthy diet. Currently, no drugs have been approved by the Food and Drug Administration (FDA) for management of these conditions. Drugs for diabetes management (eg, glucagon-like peptide 1 receptor agonists, pioglitazone) can be useful in patients with diabetes and NASH. Among patients with NAFLD, cardiovascular disease is a common cause of mortality. Thus, the AASLD guidelines recommend consideration of omega-3 fatty acids for hypertriglyceridemia management in patients with NAFLD, and statins for hyperlipidemia management in most patients with NAFLD and NASH.

Liver Disease: Hepatitis C.

Approximately 4.1 million individuals in the United States have a history of hepatitis C virus (HCV) exposure, including 2.5 million with chronic infection. Screening guidelines recommend one-time, routine, opt out HCV screening for all individuals 18 years or older. Risk-based testing is recommended for specific individuals. Although many patients with chronic hepatitis C may progress to cirrhosis, end-stage liver disease, and hepatocellular carcinoma, early treatment can prevent development of these sequelae. Management of hepatitis C has simplified significantly, and primary care physicians now can monitor and provide treatment for most patients. Adults with chronic hepatitis C who do not have cirrhosis and have not received hepatitis C treatment previously are eligible for primary care-based treatment. These patients should undergo a comprehensive pretreatment evaluation to guide treatment planning. Patients typically are treated with one of two pangenotypic regimens: glecaprevir-pibrentasvir for 8 weeks or sofosbuvir-velpatasvir for 12 weeks. Virologic cure, defined as sustained virologic response (SVR) at 12 weeks after treatment completion, should be confirmed by an undetectable quantitative HCV RNA via polymerase chain reaction test performed 12 weeks or later after treatment completion. Management results in rates of virologic cure of greater than 95% across genotypes. Patients who do not achieve SVR at 12 weeks should be referred to a subspecialist experienced in management of treatment failure.

Liver Disease: Cirrhosis.

Cirrhosis is pathologic scarring of liver tissue that leads to impaired liver function. It can result from any etiology of chronic liver inflammation and causes significant disease burden. Cirrhosis potentially is reversible through management of the cause, such as nonalcoholic fatty liver disease, viral hepatitis, or alcohol use. As liver disease progresses, compensated (ie, asymptomatic) cirrhosis may decompensate, causing ascites, hepatic encephalopathy, or variceal bleeding. Cirrhosis typically is diagnosed with a history, physical examination, and noninvasive testing, which includes laboratory tests, combination scoring indices, and imaging (eg, ultrasonography, transient elastography). Liver biopsy remains the reference standard for diagnosis. It should be used when results of noninvasive evaluation are indeterminate, when the etiology of liver disease remains unknown, or when the result may alter management. Clinicians should counsel patients about alcohol use, obesity management, and prevention of infection. Drugs with potential for hepatotoxicity should be avoided. Clinical assessment with laboratory tests and calculation of the Child-Pugh and Model for End-stage Liver Disease (MELD) scores should occur every 6 months. Clinicians should evaluate for and manage cirrhosis-related complications, including hepatocellular carcinoma, ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, esophageal varices, and other complications. Evaluation for liver transplantation is indicated for patients with a MELD score of 15 or greater, complications of cirrhosis, or hepatocellular carcinoma.

Residency Setting Association With Resident Substance Use Disorder Training: A CERA Secondary Data Analysis.

BACKGROUND AND OBJECTIVES: As the opioid crisis worsens across the United States, the factors that impact physician training in management of substance use disorders become more relevant. A thorough understanding of these factors is necessary for family medicine residency programs to inform their own residency curricula. The objective of our study was to identify factors that correlate with increased residency training in addiction medicine across a broad sample of family medicine residencies. METHODS: We performed secondary analysis of a national family medicine residency program director survey conducted in 2015-2016 (CERA Survey PD-8). We obtained data from the Council of Academic Family Medicine Educational Research Alliance (CERA) Data Clearinghouse. We analyzed residency clinic site designation as a patient-centered medical home (PCMH), federally-qualified health center (FQHC), or both, for their correlation with faculty member possession of DEA-X buprenorphine waiver license, as well as required residency curriculum in addiction medicine. RESULTS: Residency programs situated in an FQHC were more likely to have faculty members who possessed DEA-X buprenorphine waiver licenses (P=.025). Residency clinics that were both a PCMH as well as an FQHC also correlated strongly (P=.001). Furthermore, residencies with faculty who possessed a DEA-X license were significantly more likely to have a required curriculum in addiction medicine (P=.002). CONCLUSIONS: Our quantitative secondary analysis of CERA survey data of family medicine residency program directors revealed that resident training in addiction medicine is strongly correlated with both residency clinic setting (FQHC or FQHC/PCMH) as well as residency faculty possession of DEA-X licenses.

Abnormally Low Hemoglobin A1c as Harbinger of Hemoglobinopathy.

Hemoglobin A1c is frequently used in primary care to screen for and monitor disorders of glucose metabolism. A number of clinical syndromes may impact the accuracy of this laboratory value. This report describes a case of abnormally low hemoglobin A1c that was the result of an asymptomatic compound hemoglobinopathy (homozygous hemoglobin S disease and hereditary persistence of fetal hemoglobin) that had gone previously undiagnosed. Primary care physicians must be aware of such pitfalls in the use of this laboratory value and be prepared to use other values to monitor for and assess disorders of glucose metabolism.

HIV and Substance Use Disorder: Role of the HIV Physician.

The ongoing syndemic of substance use disorder and human immunodeficiency virus infection threatens progress made in preventing new infections and improving outcomes among those infected. To address this challenge effectively, human immunodeficiency virus physicians must take an increased role in the screening, diagnosis, and treatment of substance use disorders. Such treatment decreases human immunodeficiency virus risk behaviors and improves human immunodeficiency virus and substance use disorder-related outcomes. An effective response to this syndemic requires increased access to adjuvant interventions and a radical movement away from the current stigmatization and criminalization of those suffering from substance use disorders.