The Atlanta Journal-Constitution
Family doctor at forefront of taking fight to opioid epidemic
A newborn had arrived for his checkup, prompting Dr. Nicole Gastala to abandon her half-eaten lunch and brace for the afternoon crush. An older man with diabetes would follow, then a pregnant teenager, a possible case of pneumonia and someone with a rash.
There were also patients on her schedule with a problem most primary care doctors don’t treat: a former construction worker fighting an addiction to opioid painkillers, and a tattooed millennial who had been injecting heroin four times a day.
Opioid overdoses are killing so many Americans that demographers say they are likely behind a striking drop in life expectancy. Yet most of the more than 2 million people addicted to opioid painkillers, heroin and synthetic fentanyl get no treatment. Gastala, 33, is trying to help by folding addiction treatment into her everyday family medicine practice. She is one of a small cadre of primary care doctors who regularly prescribe buprenorphine, a medication that helps suppress the cravings and withdrawal symptoms that plague people addicted to opioids. If the country is really going to curb the opioid epidemic, many public health experts say, it will need a lot more Gastalas.
A new study found that even among people who had overdosed, only 30 percent were provided with buprenorphine or one of the other medications approved for treating opioid addiction, methadone and naltrexone, in the year that followed.
After a rocky start, the administration has gotten on board with addiction medications. The nation’s top health official, Health and Human Services Secretary Alex Azar, said recently that trying to recover without them is “like trying to treat an infection without antibiotics.” Last year, Congress temporarily began allowing nurse practitioners and physician assistants to prescribe buprenorphine if they go through extra training, and more than 7,000 have gotten licensed; a bill that passed the House on Friday would let them prescribe it permanently. Still, half the counties in the United States don’t have a single buprenorphine prescriber.
Gastala has to follow strict federal requirements and live with the possibility that the Drug Enforcement Administration might inspect her office with no warning. Insurers require her to jump through constant hoops to get the medication approved for her patients.
She has found that addiction treatment is incredibly complex work, not least because the patients often have unaddressed mental health problems. She has been crushed when patients drop out of treatment and conflicted about whether and when to stop treating someone who continues to use drugs.
“This is not like a newborn exam or a diabetes check or strep,” said Gastala. “It’s very complicated and takes a lot of time and effort, and can feel high risk.”
Steenhoek, 30, had started on Suboxone —the most common formulation of buprenorphine — a month earlier, while staying with her stepfather in Illinois. Now she was back at home and needed a way to keep getting the medication. She had lost custody of her 10-year-old daughter, and didn’t want to lose her 1-year-old son.
Andrea Storjohann, a nurse case manager who is Gastala’s vital partner in treating addicted patients, was waiting for her in the exam room. Storjohann keeps the buprenorphine program running while the doctor multitasks. She gauges each patient’s progress. She also tests their urine to check for other drugs and that they’re not misusing or diverting the medication. And she makes sure they’re going to therapy, which the program requires.
“In the last year, how many times have you used an illegal drug or prescription medicine for a nonmedical reason?” she asked Steenhoek.
“Like, 300,” came the reply. There was no trace of judgment on the nurse’s face.
She said she’d been having intense cravings for heroin, and had taken more than her usual dose of Suboxone in desperation one recent night.
“I’d rather you do that than go use heroin,” Storjohann reassured her.
Then it was Gastala’s turn to meet Steenhoek, asking about her support system, how often she went to therapy and whether she had a job.