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A malpractice case holds lessons for opioid addiction treatment

July 15, 2016
by Luis Giuffra, MD, PhD
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Luis Giuffra, MD, PhD

In January 1979, 41-year-old Raphael Osheroff, MD, a nephrologist, was admitted to Chestnut Lodge's Maryland facility with anxiety, depression and thoughts of suicide after outpatient treatment proved unsuccessful. He suffered from major depression. Chestnut Lodge’s medical staff (trained in psychodynamic psychotherapy and unwilling to use evidence-based psychotropic medications) prescribed for Osheroff psychotherapy four times a week for the treatment of narcissistic personality disorder. The staff claimed that any medication would mask his symptoms and interfere with the process of recovery.

Osheroff's condition worsened, and in September of that year, after seven months of unsuccessful and costly treatment, he was transferred to Silver Hill Foundation and was prescribed psychotropic medication. According to reports, his condition began to improve shortly after taking the medication. In the process, however, Osheroff lost his medical practice and ended up estranged from his family.

Osheroff’s treatment at Chestnut Lodge led to a lawsuit claiming that administrators and doctors committed malpractice by treating his severe depression with talk therapy alone when proven medications (antidepressants and mood stabilizers) were available. Osheroff won an arbitration board hearing, but both parties refused the financial award. Osheroff amended his complaint to include even more damages. The case was settled out of court in 1987. Following the settlement, Chestnut Lodge began to use medication treatment more regularly, until the Maryland center closed in 2001.

Osheroff v. Chestnut Lodge has become a landmark case in forensic psychiatry. After Osheroff, no reputable mental health practitioner will recommend treating severe major depression with psychodynamic psychotherapy alone. Previous to the case, many therapists thought, “We have to get to the root of the problem, and medications will just mask the symptoms.” The case showed mental health practitioners that they could be held liable for basing their treatment choices on intuition and personal belief rather than scientific evidence. It set a precedent that the addiction treatment community should consider in light of today’s treatment of opioid addiction.

Effective medications available

We are in the midst of an opioid crisis. Drug overdose is the leading cause of accidental death in this country. Prescription pain relievers accounted for nearly 19,000 of a total of just over 47,000 accidental overdose deaths in 2014—40%. Heroin addiction accounted for 22%, or 10,574 deaths that year. This is an epidemic that is affecting men and women, young and old, regardless of race or economic status.

Buprenorphine is a highly effective medication, which is why President Bill Clinton in 2000 signed into law the Drug Abuse Treatment Act (DATA), which allowed physicians access to participate in medication-assisted treatment (MAT) and to prescribe the drug to persons with opioid dependence. Data show that buprenorphine (and methadone) retains more patients in treatment, decreases HIV and hepatitis cases among IV drug users, decreases the number of overdose deaths, and decreases patients’ costly involvement with the legal system.

Despite clear evidence of these medications' effectiveness and their emphatic endorsement by the National Institutes of Heath (NIH) and the World Health Organization (WHO), only about 20% of persons who enter treatment for opioid dependence in the U.S. are provided medication to manage cravings. Many addiction treatment providers refuse to offer medications to persons with opioid dependence, claiming, as in the Osheroff case, that medications will only mask the problem and prevent true recovery. Many inpatient facilities refuse to treat patients who already are receiving medication for opioid dependence, and the 12-Step program Narcotics Anonymous (NA) won’t allow persons taking buprenorphine or methadone to participate actively in meetings (this is cited in NA's bulletin #29).

Why the pushback against this successful treatment option? Part of the problem is access. According to a 2014 study, only 3% of primary care physicians and 16% of psychiatrists had received the DATA waiver to prescribe buprenorphine for opioid addiction. When DATA was introduced, it allowed prescribers to have no more than 30 patients at one time at the start and then to be able to treat up to 100. That maximum number will now increase to 275 but, when faced with the estimated 2.4 million people addicted to prescription painkillers or heroin, there simply aren’t enough MAT prescribers to go around.

Another part of the problem involves the “abstinence-only” culture of some addiction treatment providers who fail to embrace scientific findings that support MAT. Just as the psychodynamically oriented clinicians at Chestnut Lodge did, these providers make treatment recommendations based on their opinions and biases, not on data and science. Their well-meaning but misguided efforts add to the problem, because abstinence-only programs for opioid-dependent patients have very low retention rates. Patients experience repeated failures in often costly residential programs (families go to financial extremes to cover facilities that will offer acupuncture, equine therapy and massage, but not MAT). Abstinence-based treatment centers regularly discharge patients into their trigger-laden natural environment without any anti-craving medication. Patients’ reduced tolerance to opioids following inpatient treatment increases their risk for fatal overdose.

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Comments

Interesting article, thanks for sharing it. However, I think the reference to NA's bulletin #29 is misleading.

Understanding the organizational structure of AA/NA is vitally important context to really get the correct meaning. Its tradition 4 states that individual groups are to be "autonomous" or self-governed. What this means is that bulletins that come from the NA board are suggestions, not directives. It's a grassroots bottom-up structure, rather than top-down like a typical business. The board exists to be of service to the groups; the groups are not there to serve the board.

The very top of the Bulletin says, "It represents the views of the board at the time of writing" (which was 1996). Each group may have different customs and viewpoints regarding MAT. Many groups are open to the use of psychotropic medications. Some groups are open but cautious. Others may openly discourage it and suggest medication as a last resort. It's similar to how there are some people that are really into "eastern" holistic medicine and others that prefer more a more "westernized" kind.

And more importantly bulletin 29 states:

"Tradition Three says that the only requirement for NA membership is a desire to stop using. There are no exceptions to this. Desire itself establishes membership; nothing else matters, not even abstinence. It is up to the individual, no one else, to determine membership. Therefore, someone who is using and who has a desire to stop using, can be a member of NA.
Members on drug replacement programs such as methadone are encouraged to attend NA meetings."

I think it does a disservice to represent AA/NA as having a single dogmatic viewpoint. It is an invaluable multi-dimensional global support group where many people have found lasting recovery and a sober community.

Terrific comment, mind explorer! As far as self-help groups go, AA and NA deserve much more credit than they get (both as autonomous groups and as world-wide organizations) for incredible growth and acceptance over the past 30 years. It's not easy to change while being true to the basic principles of the 12 steps. The more we learn about the brain chemistry of addiction, the more truth we see in the old slogans: "I am not a bad person getting good, I am a sick person getting well" and "once a pickle, never a cucumber again." It may sound simplistic but it works for a lot of us.

Having worked at both abstinence only centers and MAT centers, I see both sides to the argument. The emerging literature on the benefits of Suboxone seems to indicate a benefit for relapsing opiate users. But we have to ask who is driving its use, and that would appear to be pharma and insurance companies. My concerns are that in dealing with an opiate use epidemic, we are turning for answers to the same parties that got us here in the first place. Sixteen years ago OxyContin was touted as a panacea for managing pain, and look where that left us in time. Suboxone is an opioid and people become dependent on it. Some can even get a high from it. I have seen the difficulty individuals have had in tapering off it because they do not want to remain on it for life. If it works for an individual and he or she can function well in life without relapsing, then the cost of dependence may not outweigh the benefits of increased happiness. Perhaps we will end up with a society of millions of people dependent on Suboxone and this will be the acceptable norm, based on extant studies. Certainly, the pharmaceutical manufacturers will be happy. And the insurance companies will point to the numbers to justify their continued refusal to pay benefits for psychosocial-based treatment centers that are not MAT driven. The ethical question, which is better answered sooner than later is: do we want to live in a world of chemical solutions to the problem of addiction? If a symptom-driven approach to treatment is what we want as a society then Suboxone may be the solution. Perhaps removing cravings allows deeper therapeutic work to be done. Or perhaps there will be unintended consequences that may only emerge years from now. If this proves to be the case, will we be prepared to deal with the millions of opiate dependent people we will have created through well-intentioned medication-focused treatment? In other words, will the future be a reflection of where we are right now?

Thank you for a concise comment that accurately reflects what is going on in regard to medical and pharmaceutical solutions to synthetic opiate addiction. Methadone was clearly a socially acceptable and legally encouraged "solution" to heroin use, largely then (1970's) in inner cities and the crime that was committed to acquire the drug. Methadone is more addictive than Heroin and harder to kick. Enter Suboxone prescriptions to help methadone patients (those who receive doses in regulated clinics @$400 a month) get off Methadone.. Now what is going to assist those who have become habituated and chemically addicted to Suboxone? Most likely some Pharma Co is exploring that right now in a laboratory somewhere, eager to bring a new drug solution to market now patent has expired for Suboxone... And on and on...

Thanks all for their comments. In my view, MAT and 12 steps are not exclusive but complementary. Interestingly, when AA founder Bill W read about methadone, he asked a methadone pioneer to find a methadone for alcoholics, and AA named a methadone researcher to its board. For those, interested, you may find a video supporting AA, showing its effectiveness, and postulating a mechanism of action at:

https://www.youtube.com/watch?v=nxf3CsWBmRw

Thank you Dr. Giuffra for responding, and the video you posted is excellent! I was glued from start to finish and highly recommend it.

One area I feel has not been given nearly enough attention is what you mention at the 11:30 - 14:00 minute mark in your video regarding MAT effectiveness studies (particularly for opiate replacement pharmacotherapy). I agree with you 100%! There can be some serious limitations in their design and this seems to never be fully investigated for some reason. Maybe there's no money in that line of research?

When the details are fully examined, (such as how long clients were followed for, how "success" was specifically defined, how participants were excluded/included, and other procedural details), the evidence seems quite thin to me. Sometimes the results can be statistically significant, such as 7.1 using days versus 10.5 using days at 3 months post-treatment, but is that really a successful result for the treatment of a chronic disease?

Using short-term measures when evaluating a treatment for a chronic long-term disorder may not be appropriate and could be misleading. Many of them are funded by the drug-maker and have a high vulnerability for bias regarding how they were designed and conducted. Consequently, their external validity seems questionable and the results far from conclusive.

Suboxone is a "top-of-the-line" pharmacotherapy treatment. I wonder what the results would be of a year-long comparison study with a "top-of-the-line" full continuum of care psychosocial treatment. There could be three groups: 1) Suboxone with individual counseling, 2) the psychosocial full continuum of care treatment, and a third group with the two treatments combined.

I've seen studies where an [exercise-alone group] surpassed the effectiveness of the [exercise + antidepressant group] when followed in the long-term for the treatment of depression. Did the drug interfere with the effectiveness of the exercise treatment?
http://www.theatlantic.com/health/archive/2014/03/for-depression-prescribing-exercise-before-medication/284587/

Of course there will always be individual differences and I am for whatever works best for the particular individual, but our field desperately needs meta-analyses of current efficacy studies and new long-term studies to make sure we are really giving them the best treatment available for this chronic illness. We owe that to them before administering drugs that might have long-term unintended consequences and potentially be less effective in the long-run.

Researchers, can you help us out?

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