By necessity, many of us in the addiction treatment field have developed some special expertise in the management of opioid dependence over the past five years. An opiate epidemic is sweeping our nation, with some states hit particularly hard. Ohio has been one of those states.
Since 2009, annual deaths in Ohio from unintentional overdose (usually involving opioids) have exceeded the number of deaths occurring on our highways. Four people (most under the age of 30) die every single day in Ohio as a result of unintentional overdose. If four young people in Ohio died from meningitis every day, there would be an uproar of unimaginable proportions.
Our outpatient (Northland) and residential (The Ridge) facilities are both situated in relatively upscale suburban communities outside Cincinnati, Ohio. Over the past 10 years we have seen a steady increase in the number of people seeking help for opioid dependence. Fully 60 to 70% of new patients identify an opiate as their drug of choice. This represents a complete reversal of our patient mix of 10 years ago, when most patients seeking help were primarily abusing alcohol.
In addition, most of our patients abusing alcohol typically are over the age of 40, married, have children, and are gainfully employed. Conversely, most of our opiate addicts are under the age of 30, single, in a relationship with another user, living in a substance-promoting environment with limited or aborted education, and are unemployed or have limited employment opportunities.
To complicate matters further, most of our young opiate addicts, in the months prior to admission, have undergone a rapid escalation of their disease and suffer a rather severe deterioration in global functioning.
Most have started with oral opiate prescription medication (often from family members, friends or the handy medicine cabinet) but have progressed to the use of heroin by either snorting or the intravenous route. Heroin is readily available in the community (even to high school and college students) and is relatively inexpensive compared to the oral counterparts. It is also intensely addicting, and approximately one of every four people who experiment with heroin becomes dependent. The sharing of needles and straws is common, and approximately half of our patients who have shared a needle test positive for the hepatitis C antibody.
Shifting the approach
Another unfortunate fact is that the traditional treatment approach for opioid addiction (abstinence pathway plus education, group counseling, and a 12-Step program) has a low success rate. Despite recent advances in medication-assisted treatment (MAT), many programs around the country cling to the abstinence pathway as the only treatment modality offered.
We welcomed Hazelden’s recent announcement that it will now utilize buprenorphine on a maintenance basis for selected patients. Data collected over the past two to three years clearly demonstrate improved outcomes with the use of medication-assisted treatment (40 to 60% one-year sobriety).
We suggest that MAT should be the standard of care in opiate addiction treatment today. Medication assistance helps retain people in treatment by suppressing or eliminating the opiate cravings that can persist for months after abstinence. Retention in treatment gives people the education and the time needed to make the changes in their behavior and environment that are necessary for long-term sobriety. Completion of treatment gives these people a fighting chance against this deadly disease.
The remainder of this article will summarize our four-year experience in a suburban population with the use of the Schedule III opioid partial agonist buprenorphine combined with the opioid antagonist naloxone (trade name Suboxone).
We use an aggressive approach to the treatment of opiate dependence. To be eligible for medication assistance on an outpatient basis, all patients must be willing to commit to completing our MAT program of 15-plus months. We do not provide “medication-only” care. To date, we have had no deaths among patients while engaged in treatment, and approximately 40% of our MAT patients go on to complete treatment.
Finally, I will address the two issues most often cited as the rationale against MAT: that it is only replacing one drug with another, and that buprenorphine is being diverted primarily for its euphorigenic potential.
All patients undergo a comprehensive alcohol and drug assessment by a licensed chemical dependency counselor on their first visit. Patients who meet DSM-IV criteria for opiate dependence, and who are interested in the MAT program, are then scheduled for a comprehensive physician-performed medical history and physical examination, forensic urine drug testing, comprehensive laboratory evaluation that includes testing for HIV and hepatitis B and C, and a review of the patient’s State of Ohio Automated Prescription Report (OARRS).
Patients are asked to remain abstinent for 24 hours if they have been using a short-acting opiate, or up to 72 hours or more if they have been abusing a long-acting agent, before meeting with the physician.
Before medication is administered, the physician reviews a “Buprenorphine Informed Consent” form with the patient, which specifically addresses the risks and benefits of taking the buprenorphine/naloxone combination. We also require a signed “Treatment Contract,” which clearly spells out the requirements for continued eligibility for medication, and the consequences of unacceptable behaviors—which may include the discontinuation of medication.