How Physician Workforce Shortages Are Hampering the Response to the Opioid Crisis

The United States is in the midst of an unprecedented opioid crisis, with a provisional estimate of >93,000 opioid-involved overdose deaths in 2020 (1) and an estimated 1.6–6 million individuals with a current opioid use disorder (2, 3). The intersection of the opioid epidemic with the COVID-19 pandemic is driving increases in opioid-related fatalities as a result of the confluence of fentanyl penetration, widespread emotional stress, financial problems, social isolation, and disruptions to health care and mental health services (4–7). These new challenges are bringing greater attention to the long-standing problem of undertreatment of opioid use disorder.

Opioid use disorder is most effectively managed with medications, some of which can be prescribed in primary care and other nonspecialty treatment settings, thereby facilitating integrated care models. Yet only 18% of adults with opioid use disorder are receiving first-line, evidence-based lifesaving treatment with medications (3, 8), a proportion that has remained unchanged for the past decade, even as overdose deaths have markedly increased. This treatment deficit reflects a shortage in addiction medicine–trained providers.

Confronted with persistent gaps in opioid use disorder treatment, health systems and public health departments are looking for new ways of engaging and retaining patients in care (9, 10). Increased funding is available to do so, including the State Opioid Response Grants of the federal Substance Abuse and Mental Health Services Administration (SAMHSA) ($930 million), the National Institutes of Health Helping to End Addiction Long-term Initiative ($945 million), new Health Resources and Services Administration (HRSA) programs to expand access to opioid use disorder treatment in primary care settings (including in rural and underserved areas), and numerous state and municipal programs. New strategies that have been implemented or expanded in recent years include medication initiation in emergency departments (11), peer navigation to link patients to treatment after a nonfatal overdose (12), and addiction consultation services for hospitalized patients (13).

Although these initiatives hold promise, their impact has been impeded by addiction workforce shortages. These shortages present a major roadblock to efforts to rapidly expand opioid use disorder treatment and reduce opioid-related overdose deaths. We describe the scope of the addiction workforce problem and present a case study to illustrate how this workforce shortage constrains the ability of health systems to address the gaps in opioid use disorder treatment. We then identify the historical roots of this shortage and summarize current initiatives and recommendations to ameliorate its impact on the response to the opioid crisis.

National Scope of the Problem

Although the addiction treatment workforce spans many fields of training (including counselors, social workers, psychologists, nurses, and peer educators, among others), the workforce shortage is particularly acute with respect to physicians. Many types of medical and behavioral health providers serve important roles, but because physicians are particularly integral to expanding access to medications for opioid use disorder and have not historically been employed in addiction treatment settings, they are the primary focus of this article.

Addiction became a recognized physician specialty eligible for board certification only in 1991. According to the Association of American Medical Colleges, <2,500 physicians nationwide are certified in addiction medicine, and only approximately 2,000 are certified in addiction psychiatry (14). By contrast, 22,500 cardiologists practice in the United States—nearly five times the number of addiction physicians (15). With an estimated 2–6 million Americans with opioid use disorder, this leaves approximately one addiction physician for every 450–1,300 individuals in need of treatment. In addition to being insufficient in number, the addiction physician workforce does not reflect the racial and ethnic diversity of the populations affected by opioid use disorder. Most practicing addiction psychiatrists are White, and in 2018 underrepresented minority groups made up <0.1% of the pool of addiction medicine and psychiatry fellows (16). The lack of diversity among providers can present a barrier to improving treatment access and retention for Black and Latinx patients, who may be more likely to enter treatment and to have better treatment outcomes when they receive care from providers who have a shared experience and understanding of structural racism and related social determinants of health (16–18).

Although opioid use disorder treatment has increased in some regions over the past decade, primarily through modest growth in buprenorphine prescribing (19), this increase has not kept pace with the growth in need (19, 20). Treatment shortages are particularly acute in rural areas: nearly 60% of rural-dwelling Americans live in a county without a single buprenorphine-waivered provider, and 40% of rural counties have no outpatient addiction treatment facilities that accept Medicaid (21, 22). Moreover, racial and economic disparities exist in access to opioid use disorder treatment, with buprenorphine prescribing primarily benefiting White and higher-income populations (23–25). Most buprenorphine treatment visits are covered by private insurance or paid for out of pocket, which severely restricts access of lower-income groups. Black Americans have significantly lower odds of receiving buprenorphine than White Americans, despite evidence that the prevalence of opioid misuse is similar in these two groups (25–27).

How the Addiction Workforce Shortage Affects an Innovative Program

In response to the opioid overdose crisis in New York City (NYC), in 2017 the NYC Mayor’s Office launched the ambitious HealingNYC initiative, which commits $60 million each year to programs aimed at reducing opioid overdose death (28). HealingNYC leverages the resources of the city’s public hospital system (NYC Health + Hospitals [H+H]) and the NYC Department of Health and Mental Hygiene to increase access to opioid use disorder treatment. A key component of this program is the introduction of addiction consultation services in the public hospital system through a new program called Consult for Addiction Treatment and Care in Hospitals (CATCH).

In keeping with the typical organization of inpatient subspecialty care, addiction consultation services provide expert evaluation, diagnosis, and treatment for patients with substance use disorders who are hospitalized, regardless of their admitting diagnosis. A key component is medication initiation while patients are hospitalized and linkage to ongoing pharmacotherapy as part of the discharge plan. Addiction consultation services show promise for improving outcomes among hospitalized patients with opioid use disorder (29–33). In an ongoing pragmatic trial, we are examining the effectiveness of CATCH as the program rolls out in the six largest acute care hospitals of the H+H system (34).

CATCH teams consist of a medical provider, a social worker or addiction counselor, and a peer counselor; each hospital has three CATCH teams. Funding and administrative structures were in place to begin hiring in late 2017, but a lack of qualified physician and nurse practitioner (NP) applicants delayed the start date at some hospitals by 6 months. Although the program was successfully initiated at all six hospitals, only two of them were fully staffed with CATCH medical providers on their start date. The need is substantial: CATCH teams consult on >500 patients per month but still reach only about half of the patients who are admitted with a documented history of substance use disorder.

A related barrier to the CATCH program’s implementation and effectiveness is a shortage of office-based medical providers in the community who can continue outpatient treatment for patients who started medication for opioid use disorder while hospitalized. H+H has worked to develop a primary care workforce that can deliver addiction care in the context of regular medical services, but experience and comfort levels have grown more slowly than the moment demands. Although the system now has primary care addiction treatment available at all 11 acute care facilities and in many outpatient clinics, it remains challenging to arrange treatment postdischarge. The CATCH program illustrates how the impact of increased funding and innovative programmatic responses to the opioid crisis can be compromised by shortages in addiction medicine providers that threaten the effectiveness of even well-resourced, targeted, and thoughtfully implemented programs.

How Did We Get Here?

Regulatory Constraints on Medications for Opioid Use Disorder Treatment

The United States has a long history of restricting access to medication for opioid use disorder treatment. Dating back to 100 years ago when tens of thousands of physicians were indicted for maintaining opioid-addicted patients on morphine, law enforcement has constrained physician treatment of patients with opioid use disorder. When the first evidence-based treatment for opioid use disorder was introduced in 1973, in the form of methadone maintenance treatment, it was relegated to highly regulated opioid treatment programs. Today, methadone remains the most regulated medication in the United States (35).

When buprenorphine received approval for the treatment of opioid use disorder in 2002, it came with the caveat that physicians complete 8 hours of dedicated training and receive a special “X-waiver” from the Drug Enforcement Administration (DEA) allowing them to prescribe, while placing caps on the number of patients they can treat. NPs and physician assistants (PAs) were prohibited from prescribing buprenorphine until 2016, and they can now do so only after completing 24 hours of training. No such restrictions exist on prescribing other opioids, including more dangerous medications such as oxycodone and fentanyl. Currently, only 5% of all medical providers (10% of primary care providers) are waivered to prescribe buprenorphine, and regulations continue to prohibit the prescribing of methadone (except for pain) in medical settings (36–38). With a legacy of separating opioid use disorder treatment from mainstream medical care, the United States has been unable to fully leverage existing health care systems to respond rapidly and effectively to the current opioid crisis.

Medical Education

The average medical school curriculum dedicates only a few hours—out of 4 years of training—to addiction (39). Barely half of the approximately 10,000 residency programs nationwide require curricular content on addiction prevention and treatment, and in many of these programs, addiction content is provided for only 4–12 hours over several years of training (39, 40). With historically limited curricular training, the medical faculty and supervising physicians of today’s trainees are ill-equipped to oversee the scale and complexity of care necessary to appropriately respond to today’s opioid epidemic.

Medical training generally involves both didactic and clinical education. However, the bulk of skill acquisition occurs under an apprenticeship model and across a variety of clinical settings (41). Although many patients with substance use disorders are in clinical training environments, few of them are receiving evidence-based treatment under a long-term outpatient care model for substance use disorder. Trainees who are never exposed to successful treatment for substance use disorders do not gain the required clinical knowledge about effective options for managing these disorders. Among recent family medicine graduates, for example, just 10% reported being trained to prescribe buprenorphine, and only 7% had ever prescribed it (42). The idea of a career in addiction treatment is unlikely to ever cross the mind of young physicians, many of whom may lack experience and role models.

Stigma

Because few medical providers are exposed to effective opioid use disorder treatment and successful patient outcomes, there is a misperception that opioid use disorder cannot be treated effectively. This sets up a confrontational situation that pits provider against patient (especially in high-acuity settings such as hospitals and emergency departments), with some providers considering patients with opioid use disorder an unnecessary burden and labeling them as “drug seeking” or “addicts who will be back again” (43). Despite overwhelming evidence of the effectiveness of medications for opioid use disorder, many providers, patients, and policy makers still hold views that it is “just replacing one drug for another” (44) and that total abstinence (including from prescribed medication) is the only outcome that matters (14, 45). These misperceptions can lead providers to blame patients or to incorrectly believe that treatment is ineffective, while ignoring the social determinants of health and structural inequities (such as housing, food insecurity, criminal justice involvement, and violence) that make treatment challenging (18).

These persistent sources of stigma likely intersect with other biases in care settings that treat a disproportionate number of patients who are people of color or economically deprived. Inadequate reimbursement, particularly by public insurers, may further detract providers from the field (46, 47). The result is less treatment for patients, less experience for providers, lack of mentorship, and persistent stigmatizing attitudes. As a result of the historical neglect of opioid use disorder treatment, communities in the United States are left with an antiquated addiction treatment system that is unattractive to providers and does not meet the needs of patients.

Current Efforts and Potential Solutions to Grow the Addiction Workforce

As detailed in this article, strategies that could effectively expand the addiction workforce include federal programs, medical education initiatives, and continuing medical education (Table 1). At the state and local levels, although some of the billions in settlement dollars gained in lawsuits against opioid manufacturers could be allocated to workforce development, such allocation has not been prioritized (48, 49).

Federal Programs for Workforce Development

Federal lawmakers and agencies have begun to respond to addiction workforce shortages. Bipartisan legislation, the Opioid Workforce Act of 2021 (50), proposes to add 1,000 graduate medical education positions over the next 5 years in hospitals that have, or are establishing, accredited residency programs in addiction medicine, addiction psychiatry, or pain medicine. HRSA has started offering a federal loan repayment program specifically targeting health care providers who will work in underserved areas to expand access to addiction treatment. In June 2020, HRSA also issued grant awards ($20 million in total) to support addiction medicine fellowship programs.

Although these new federal programs are a step in the right direction, additional large-scale, timely, and sustained action is needed. Existing programs that were designed to meet the public health needs of rural and underserved areas could play a role, but they require significant and rapid expansion to meet treatment needs. Examples are the Graduate Psychology Education Program, Opioid Workforce Expansion Program, and Behavioral Health Workforce Education and Training Program, which work with members of local communities to provide interdisciplinary treatment for mental health and substance use disorders. The HRSA Title VII pipeline programs could similarly be directed to include an explicit focus on increasing evidence-based opioid use disorder treatment. These programs include the Health Career Opportunity Program (commonly known as HCOP) and Centers of Excellence, which help recruit and retain minority and disadvantaged students who are more likely to practice in rural and underserved areas. Similarly, programs such as the SAMHSA Minority Fellowship Program could be expanded and more explicitly focus on medical providers who can prescribe medications for opioid use disorder, including physicians and NPs. By cultivating interest in and commitment to providing opioid use disorder treatment among a larger and more diverse group of providers, infusing additional resources into these programs could offer a sustainable pipeline for addressing the workforce shortage in the most underserved areas while advancing racial equity.

Medical Education Initiatives

Universities have an important role to play in developing the robust pipeline that is needed to address rural and underserved workforce challenges by recruiting individuals who are more likely to practice in these settings. For example, the Robert Wood Johnson Foundation has invested in the Summer Health Professions Education Program (formerly the Minority Medical Education Program), a successful 30-year model program that has served >30,000 college students (51). Data show that this program has significantly increased the number of diverse candidates graduating from medical and dental schools. The combination of academic support, mentoring, and career development contributes to positive workforce outcomes.

Although undergraduate training is necessary to build a robust and sustainable addiction workforce, it will be years before these trainees are able to provide care. Medical school and residency training programs have the potential to contribute more immediately to addressing the opioid crisis. Preclinical medical education and training need to go beyond curriculum change to require practice-based knowledge of basic addiction treatment, including a focus on medications for opioid use disorder, consistent with expectations for fundamental skills in other areas of medicine. For example, the state of Massachusetts organized four of the larger medical schools to collaborate on a shared curriculum to fulfill state-level buprenorphine DEA X-waiver training requirements for all medical students before graduation (52, 53). In New York, the public H+H system has residents rotate through primary care buprenorphine clinics. Modeled on a successful program developed at Yale University (54), the goals are to improve knowledge acquisition for residents and attending physicians, expand treatment availability, and spur a larger culture change. This model has positive impacts on multiple levels for trainees and patients alike, but its implementation has been slow for the very same reason it is needed: a lack of addiction-trained faculty to serve as mentors.

Medical education programs on addictions could also be used to enhance diversity, equity, and inclusion in addiction treatment. One example is a 5-year training grant funded by SAMHSA, the Recognizing and Eliminating disparities in Addiction through Culturally informed Healthcare (REACH) Program, which offers didactic teaching and mentorship in addiction treatment for underrepresented minority medical students, residents, and advanced health professional students (16, 55). The expansion of REACH and similar models, along with stable funding, could have a meaningful impact on the size and the diversity of the addiction physician workforce.

Transforming Current Medical Providers Into an Effective Addiction Treatment Workforce

A particularly encouraging trend flows from the 2016 passage of the Comprehensive Addiction and Recovery Act (56), enabling NPs and PAs to obtain buprenorphine waivers. From 2016 to 2019, the number of waivered clinicians per 100,000 population in rural areas increased by 111% (57). NPs and PAs accounted for more than half of this increase. In rural areas, broad scope-of-practice regulations, which give NPs and PAs greater prescribing authority, were further associated with twice as many waivered NPs per 100,000 population compared with areas with a restricted scope of practice (57). Rapid growth in the number of waivered NPs and PAs holds promise for scaling up access to these prescribers and extending physician impact in states requiring collaborative agreements.

Waiting for the pipeline to produce independently practicing addiction providers is a long-term solution, but to respond to the present crisis, mentorship and guidance are needed now for currently practicing providers. Several programs and models exist to fulfill this need, although they remain underused. The SAMHSA-funded Provider Clinical Support System (commonly known as PCSS) offers high-quality training modules, audio lectures, discussion forums, and one-on-one direct expert mentoring, as well as access to free buprenorphine waiver training (58). The Opioid Response Network is another free program founded through SAMHSA to provide technical assistance to programs and providers. The Extension for Community and Healthcare Outcomes (ECHO) program has effectively increased the number of buprenorphine prescribers in rural areas (59), and it could be more widely used in urban and suburban health systems. For example, H+H now uses the ECHO platform to expand the number of buprenorphine providers across its large urban public system. The H+H ECHO has increased the number of providers actually prescribing buprenorphine, has assisted in clinical dilemmas, has improved self-efficacy and knowledge, and, importantly, has developed a supportive community to foster systemwide champions (60).

Recognizing that primary care providers are already overburdened, some health systems have introduced collaborative care models for opioid use disorder treatment that can support generalist practitioners in providing addiction care. A pioneering example is the Massachusetts nurse care manager model, which places a nurse care manager in primary care clinics to comanage opioid use disorder with primary care providers (61). This model reduces the burden on primary care providers while educating them about buprenorphine treatment and maintaining a high volume of treated patients. The Massachusetts statewide dissemination of this model achieved a 375% increase in buprenorphine-waivered physicians within 3 years and a large increase in the number of patients initiating office-based buprenorphine treatment (62). The model has been adopted in other areas, but a lack of addiction-trained nurses and payment structures supporting this role has limited its broad dissemination (63).

Increased integration of opioid use disorder treatment into mental health care could also have a positive impact, given high rates of comorbid psychiatric conditions, especially depression, anxiety, and posttraumatic stress disorder, among patients with opioid use disorder. There are nearly 39,000 practicing psychiatrists in the United States (15), yet most do not routinely offer medications to manage opioid use disorder (64), reflecting many of the same barriers cited by primary care providers—namely, lack of knowledge and concerns about practice fit and attracting undesirable patients (64, 65). Yet with extensive training in behavioral interventions, along with the ability to treat co-occurring mental disorders, psychiatrists are well positioned to provide medication for opioid use disorder.

New Practice Models and Regulatory Reforms

The worsening opioid crisis and greater barriers to treatment access posed by the COVID-19 pandemic have stimulated new treatment models and calls for regulatory easing. Telehealth has great promise for expanding access to effective treatment, particularly in rural areas (66, 67). Spurred by COVID-19–related social distancing measures and facilitated by the temporary relaxation of regulations under the federal emergency order (68), buprenorphine treatment is now routinely provided with only a telephone or video visit (60, 69, 70). In addition, for patients in methadone maintenance treatment, limitations have been relaxed, allowing for take-home doses of up to 28 days with remote visits (68). These new treatment models hold particular promise for rural patients, who otherwise have to travel for hours to reach the nearest provider, and they could ease treatment barriers even for those living in better resourced areas. However, the sustainability of these models relies on continued regulatory easing, which is not guaranteed, and on the availability of addiction treatment providers, who remain in short supply.

In May 2021, the U.S. Department of Health and Human Services released updated guidance that allows physicians and most nurses to be eligible for an X-waiver DEA number to treat up to 30 patients with buprenorphine without having to undergo additional training (63, 71). Although this updated guidance is a step in the right direction, it alone will likely prove insufficient unless resources are dedicated to expanding pipelines for the addiction workforce and addressing the structural issues of stigma and poor reimbursement rates that keep providers from entering the field. Currently, even among prescribers who were motivated enough to complete the required training and receive their X-waiver, one in four has never written a buprenorphine prescription, and only 13% are prescribing near their patient limit (38).

In summary, the response to the opioid crisis faces two interlinked challenges: First, individuals with opioid use disorder are not receiving evidence-based and lifesaving treatment because of a shortage of providers; second, the current shortage is making it difficult to educate and mentor future addiction treatment providers. To swiftly ameliorate the opioid crisis, it is imperative that health systems retrain and use their existing providers and structures to increase access to opioid use disorder treatment in primary care and mental health settings and connect patients to specialty telehealth services. Particular attention should be placed on improving buprenorphine access in rural, low-income, and racial-ethnic minority populations. Funding structures need to be developed that incentivize the primary care workforce to increase their delivery of office-based buprenorphine treatment by supporting collaborative care models and growing the number of PAs and NPs qualified as buprenorphine prescribers. Health systems could adapt ECHO and similar learning collaborative models to cultivate local champions, who can, in turn, encourage and supervise colleagues in providing addictions care as part of routine practice.

Conclusions

For those physicians experienced with addiction medications, opioid use disorder treatment is highly effective, easily integrated with regular medical care, and often professionally rewarding. However, decades of poor decisions and regulatory barriers have led to a dearth of available medical professionals. A growing chorus is calling for changes in federal policies, including increasing access to medication by removing X-waiver requirements for buprenorphine prescribing and easing regulations on methadone (18, 72–75). Although these changes could have some immediate positive impact, the response will be muted if there are not enough knowledgeable providers who are able and willing to prescribe these potentially lifesaving medications.

Comprehensive strategies for workforce development, spanning classroom and clinical training settings, mentoring and continuing education for practicing professionals, and structural reforms for integrating addiction treatment into mainstream primary care and mental health settings are urgently needed. We recommend the following actions. First, increase the pipeline of trainees who are prepared to treat patients with opioid use disorder, particularly in rural and underserved areas, by passing the Opioid Workforce Act, redirecting HRSA Title VII programs to focus on the areas hardest hit by the opioid crisis, investing some of the opioid settlement funds in workforce development, and prioritizing funding for programs that train clinicians from underrepresented minority groups. Second, expand medical trainees’ knowledge by requiring medical schools and Accreditation Council for Graduate Medical Education (commonly known as ACGME) residency programs to include clinical management of opioid use disorder, emphasizing the use of medication. Last, increase financial and regulatory support for innovative care delivery models in primary care and mental health settings, enhanced reimbursement and bundled payments for collaborative care models, and the expansion of telehealth services.