A Career in Addiction Medicine
 : An Interview with Patrick G. O’Connor, MD, MPH, FACP


Abstract

Dr. Patrick O’Connor is the Dan Adams and Amanda Adams Professor of General Medicine and Chief of General Internal Medicine at Yale University School of Medicine and Yale-New Haven Hospital in New Haven, Connecticut. Dr. O’Connor came to Yale as a fellow in the Robert Wood Johnson Clinical Scholars Program at which time he also received a MPH from the Yale School of Public Health. As Chief of General Internal Medicine at Yale he led several new initiatives in patient care, education, and research and has overseen a 3-fold expansion in the size of the faculty and 10-fold increase in research funding.
 Dr. O’Connor’s research has focused on the interface between primary care and addiction medicine. Specific topics within his research area have included: 1) the integration of primary care and substance use disorder treatment services, 2) strategies for primary care-based opioid detoxification and opioid maintenance for the treatment of opioid use disorder, 3) strategies for managing unhealthy alcohol use and alcohol use disorder in primary care settings, 4) medical education about addiction, and 5) addiction health policy. He has written over 200 scientific papers on these topics and his work has been published in leading medical journals including The New England Journal of Medicine and JAMA. Among these publications is the first randomized trial of buprenorphine in primary care. More recently, he served as an author on Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. His research has been funded through the receipt of numerous grants from the National Institutes of Health (NIH) and from foundations. He has also collaborated with federal agencies such as The White House Office on Drug Control Policy and The National Institute on Drug Abuse (NIDA) along with addiction-focused organizations in academia and the private sector.
 As Yale’s Chief of General Internal Medicine, Dr. O’Connor has recruited several leading clinical investigators whose work focuses on critical topics in health outcomes and health services research on issues such as cancer, cardiovascular disease, HIV, stroke, health disparities, and patient safety. His faculty also includes several physician-investigators and clinician educators whose work focuses on addiction and he has established The Yale Program in Addiction Medicine. He is currently the Co-principal investigator on two NIDA-funded career development programs: The Yale Drug use, Addiction, and HIV Research Scholars (DAHRS) program, and The Research in Addiction Medicine Scholars (RAMS) Program.
 In the area of addiction medicine, Dr. O’Connor has received numerous national honors for his efforts in research, education, and patient care. He is the Immediate Past President of the American Board of Addiction Medicine (ABAM) and the Addiction Medicine Foundation (TAMF), Past-President of the Association for Medical Research and Education in Substance Abuse (AMERSA), and is currently a member of the new Addiction Medicine Examination Committee for the American Board of Preventive Medicine. As Chief of the Section of General Internal Medicine at Yale, he received the first annual Chief’s Recognition Award from the Society of General Internal Medicine (SGIM) and the Association of Chiefs of General Internal Medicine (ACGIM). He also received the McGovern Award from AMERSA in November 2017. Dr. O’Connor recently sat down to talk about his career path, his research in addiction medicine, and his advice for those interested in addiction and pain medicine.
 As a clinician, how do you think about pain? I think about pain as a common and critical symptom that patients present with that can have a wide variety of causes, as well as various effects on patient functioning and well-being. My responsibility as a physician is to understand the patient’s experience with pain so I can help them figure out the source, understand preventative and treatment options, and to consider how pain is impacting their ability to function and well-being. I try to think about pain as holistically as possible – not only am I trying to address a person’s symptoms, but I am also trying to help with the effects on other parts of life, from other comorbid medical effects to functional and quality of life issues.
 Your research focuses on primary care and addiction – could you tell us a little about your work?
 I came into medicine wanting to practice primary care general internal medicine; however, as a resident, I got bit by the research bug. So I decided to become a fellow in the Yale Robert Wood Johnson Clinical Scholars program, where I developed a research focus on understanding how primary care physicians can do a better job diagnosing and treating addiction in primary care and other general medical settings. Addiction is prevalent in general medical settings – early in my career I did not know much about how to address it. Thus, I needed to do a lot of self-directed learning on addiction. Upon completing the Clinical Scholars Program, I decided to become a physician-investigator in order to leverage and expand the primary care setting as a place where addiction can get its proper due through research. I was fortunate to have the opportunity to join the Yale faculty to pursue this career path.
 At the time I joined the faculty in 1988, there was an explosion of HIV among individuals who injected drugs – this was a big concern in the addiction field at the time and heroin was the most common drug being injected. Fortunately, methadone maintenance had been established as a highly effective treatment for opioid dependence. Unfortunately, at the time, access to methadone maintenance was severely limited and as a result, patients who needed treatment were forced to join waiting lists that could force them to wait for 6 to 12 months or more before getting help. As a result, while they were waiting for treatment, these patients would often continue to use heroin and suffer the consequences of this use including the acquisition or transmission of HIV infection, heroin overdose, and in many cases, death.
 Methadone maintenance, while highly effective, is restricted to a relatively few federally-licensed programs and is thus not available in primary care or other general healthcare settings. The question at the time was: can we help patients, who were unable to gain access to methadone treatment, by leveraging the much more widely available primary health care system? To answer this question, my first studies recruited individuals who used heroin, most of whom were on methadone maintenance waiting lists, and offered them heroin detoxification in a primary care setting using techniques we developed specifically for use by primary care physicians. Once detoxified and heroin free, we would put them on naltrexone, an opioid blocker, as a way to help prevent them from using heroin again.
 What we found in these primary care-based opioid detoxification studies is that we were really good at “detoxing” patients; we could get patients heroin free safely quite well. However, where we failed is what happened after detoxification. While we were successful getting them to start naltrexone, we couldn’t get them to stay on naltrexone. As a result, the patients would relapse to heroin use at very high rates and were back to “square one.”
 Despite this negative finding concerning achieving sustained reductions in heroin use, we did demonstrate that we could utilize primary care as a site for engaging patients in treatment for opioid use. The next question was: how could we both engage them in treatment and keep them in treatment successfully? At that time, research was being done at Yale on buprenorphine, a partial opioid agonist, as an alternative to methadone for the treatment of opioid dependence. It was demonstrated that buprenorphine maintenance was as effective as methadone when used in specialized opioid maintenance programs and was also safer to use – in particular there is a lower risk of toxicity and overdose.
 With this information in hand, we next performed the first-ever randomized clinical trial (RCT) which compared the use of buprenorphine in a primary care setting vs. buprenorphine in a specialized opioid-maintenance clinic. We demonstrated that patients treated in primary care did just as well as those treated in the specialty treatment program. This study took place in the mid-1990s. Subsequently the Drug Addiction Treatment Act of 2000 (DATA 2000) was signed into law by President Clinton and allowed properly trained primary care physicians to treat opioid dependence in their offices using buprenorphine once it was approved by the FDA. This approval occurred in 2002.
 In 2000, aside from research studies, there were 0 patients on buprenorphine and about 500,000 on methadone maintenance in the US; as of 2012, there were approximately 750,000 patients using buprenorphine and 500,000 on methadone maintenance. So the treatment options are expanding, which is good. Going to a methadone maintenance clinic can be hugely stigmatizing for some patients, so for unfortunate yet understandable reasons, they will not accept treatment in these settings. However, many will find treatment for a substance use disorder in a primary care setting, where other patients are being treated for things like diabetes, heart disease, etc., more acceptable and will thus get the help that they need.
 Since this early study and FDA approval of buprenorphine, investigators at Yale and elsewhere are looking at refining how buprenorphine is used in primary care, what kinds of patients we should be treating, what kind of counseling they require, and other ways we can help these patients receive treatment for their addiction. In addition, we are collaborating with physicians in other settings to further expand how this treatment could be provided. For example, in an examination of the role of emergency departments in initiating buprenorphine treatment, we collaborated with Dr. Gail D’Onofrio, Chief of Emergency Medicine at Yale and demonstrated improved outcomes when buprenorphine was started in the emergency department and patients were referred to primary care for ongoing treatment. So this approach moves beyond primary care. Treatment options continue to expand, but there’s a lot more work to do.
 In parallel, I have investigated treating alcohol use disorder using naltrexone in primary care settings. One study found that we can treat these patients just as well in primary care as you can in specialty care programs – again reinforcing the idea of expanding treatment options by incorporating primary care into the menu of options for patients in need.
 In these research areas, progress has been greatly helped by the ability to recruit an “all-star” group of faculty in General Internal Medicine who have become leading physician scientists and clinician educators in Addiction Medicine. Our group is extremely strong and have led national and international efforts to get General Internal Medicine and other primary care physicians and providers to focus on providing effective evidence-based care for addiction and pain to patients and their families.

 How has the field of addiction medicine evolved since you started working in this field? And how has our understanding of pain in medicine evolved since you started? Addiction medicine as a specialty didn’t exist when I started working in this field. For decades there was an understanding by practitioners in the field that we needed to do something to bring addiction into the mainstream of medicine. The American Board of Addiction Medicine (ABAM) was created in 2007 with the goal of certifying doctors who were experts in addiction medicine and in order to gain recognition of this new field as a subspecialty by the American Board of Medical Specialties (ABMS). Subsequently in 2015, ABMS approved addiction medicine as a new subspecialty. We offered the first board exam for this new subspecialty in 2017 and we will award board certificates based on this exam this year. Addiction medicine is the only ABMS subspecialty in which physicians who are board certified in any of the 24 primary ABMS specialties such as internal medicine, psychiatry, family medicine, etc., can sit for the certification exam. Thus, physicians from all medical specialties can be certified. There are now 52 addiction medicine fellowships currently being offered including Yale’s program which is overseen by Jeanette Tetrault, MD. So it’s very exciting: an entirely new field was created. This has really helped to legitimize addiction medicine. My hope is that every medical school has a fellowship in addiction medicine – our goal is to have 125 fellowships by 2025.
 Pain in some ways is more complicated. Early in my career, we were hearing that doctors were doing a poor job treating pain, and then seemingly out of the blue, pain became “the 5th vital sign”. Pain scales were suddenly being administered everywhere in the healthcare system. The good part of this process was that as doctors we were being called upon to take pain seriously. Another consequence, which was not good, was intense pressure on doctors do everything they could to treat pain including the use of “fancy” new opioid medications that were rapidly flooding the market. Patients were demanding strong medications, pharmaceutical companies were crawling over each other to get powerful new opioids to market, and doctors obliged by writing prescriptions for these medications in record numbers. It was a perfect storm: the focus on pain and the appearance of new, supposedly “non-addictive” painkillers – which helped fuel the opioid crisis we are experiencing currently.
 So now we’re reckoning with the opioid crisis. As physicians we are, in part, responsible for creating it and now we are trying to catch up and do the right thing. One major issue that has become clear is that the evidence that opioids are effective at treating chronic pain is close to zero. There is no argument that opioids are effective treating acute, short term pain such as that which results from an injury or in association with surgery. However, for chronic pain issues, there is no such evidence. Yet, millions of Americans have received opioids for chronic pain with questionable benefit and very often, unquestionable harms.
 In managing pain, we have to think much more carefully and consider a broad range of treatment approaches including physical therapy, exercise, acupuncture, and other non-pharmacologic approaches along with the use of non-opioid analgesics when indicated before considering the use of opioids. If opioids are indicated, their use should be thoughtfully considered with attention to clinical effectiveness, patient safety, and appropriate dosing and duration of therapy. The potential of addiction must always be considered and incorporated into how patients are safely managed. Thus, there has been a big change in how we look at pain and addiction since I’ve started.
 In all, the current opioid crisis has been tragic for patients who have suffered overdoses and for their families and loved-ones. Now, doctors and policy makers are trying to get things going in the right direction concerning the issues of addiction and pain management.
 How did you become interested in this line of work? How did you come to be a physician scientist at Yale?
 I was an Internal Medicine resident at the University of Rochester, which was (and still is) a premier institution for primary care. I came to Rochester with the intention of hanging up a shingle and opening up my own practice. When I was a resident, however, one of the program faculty invited me to take part in a research project, a clinical trial of a medication to treat obesity. Through this career-changing experience, I realized I really enjoyed research. This led me to Yale and the Robert Wood Johnson Clinical Scholars Program. So I cut my teeth as a young clinical investigator here and honed my focus on addiction research. I joined the faculty after completing the Clinical Scholars program and have been at Yale ever since. I love being at Yale – as a place to learn and study, to teach and practice, and to do world class research, it’s a wonderful place – second to none!
 What are big gaps in our understanding of pain and addiction?
 Concerning pain, our biggest gap in understanding relates to knowing the causes and management of chronic pain. This gap is from basic to translational science to clinical research to population-based, community health studies. It’s such a complicated issue and there is so much more to learn – we’re really just scratching the surface.
 With addiction, in many ways we were much further along than we are with chronic pain. Some of the basic mechanisms of addiction are well understood and many effective treatments have been developed. In my view, the big gap with addiction is implementation science – getting those effective treatments in the hands of healthcare providers and to the patients who need them.
 A good example of this addiction treatment gap is pharmacotherapy for alcohol use disorder. If you compare the treatment efficacy of FDA-approved medications such as naltrexone in treating alcohol use disorder to that of medications used to treat other diseases such as depression or preventing diseases such as deep vein thromboses or myocardial infarction, using the metric of “number needed to treat,” medication treatments for alcohol use disorder stack up quite favorably. However, these medications are dramatically underutilized, because doctors are not aware of these medications and may not consider treating patients with alcohol use disorder in the first place. With opioid use disorder, it’s the same thing: we have effective medications but the people who need them aren’t getting them. The federal government estimates that only 10 percent of Americans who have a substance use disorder get effective treatment. How would we feel if only 10 percent of Americans with cancer or diabetes, or hypertension received the necessary treatment? We need to do a much better job.
 What advice do you have for medical students who will be treating patients with addiction and chronic pain issues in the future?
 First, medical students should realize that addiction is highly prevalent as are the medical, psychological, and social comorbidities that accompany it. Secondly, physicians and those in training should take full responsibility for addiction when they see it. Addiction is a chronic, relapsing disease that requires care and attention. Students need to take every opportunity to learn about addiction in class, in their clerkships, in electives, etc. The same goes for chronic pain. Fortunately, at Yale, there are now two committees that are in the process of revamping the medical school curriculum on addiction and pain. Concerning addiction, expectation is that there will be an addiction “thread” that begins at orientation and continues throughout all aspects of the curriculum right up to graduation. In the end, this will allow our students to be much more confident and competent to deal with addiction by the end of medical school and beyond.
 The same approach needs to be taken for pain. Physicians need to take a holistic, patient-centered approach, as physicians from every medical specialty will encounter patients with pain.
 In terms of the specific issue of opioids, future doctors shouldn’t just prescribe them “willy-nilly” – the same way they would not prescribe medications to treat diabetes or cancer without careful consideration of effectiveness and safety. Prescribing opioids needs to be done in a careful and coordinated fashion, other specialists involved in the patient’s care should be on board when they are prescribed, and doctors should plan ahead carefully regarding when they will be discontinued. Good “prescription hygiene” should be used as well: ensuring the right dose and duration are documented, etc. Also, a plan should be in place for when they will be discontinued – this can help prevent addiction that can sometimes occur when they are used on a chronic basis.
 Medical students should embrace addiction and chronic pain as core issues that patients will be coming to them with for help. As future physicians, they should approach these patients in a patient-centered and holistic way, so they can help them live healthier, more productive lives. Medical students who want to specialize in addiction medicine can now do so and thus become effective practitioners, researchers, and leaders in this exciting new field.