The names of emerging drug threats come and go, but for years now opioid dependence has remained the most prevalent and puzzling issue being addressed and analyzed in the nation’s public and private drug treatment facilities. Some communities continue to battle a prescription drug misuse epidemic with no clear end in sight, while other locations have seen a resurgence of street heroin, and few leaders believe any other drug phenomenon stands a chance of eclipsing the societal impacts of opioid addiction.
Just as there appears to be little possibility of declaring imminent victory against the opioid problem, so too does it seem unlikely that proponents of drug-free and medication-assisted treatment approaches will achieve a complete meeting of the minds anytime soon. While some traditionally 12-Step based facilities such as Hazelden have recently opted to allow some of its patients to receive maintenance dosing of buprenorphine while in residential treatment, the movement in that direction has hardly been a groundswell to this point among the most influential treatment centers nationally.
On one point, members of both camps steadfastly agree: Opioid-dependent patients can benefit greatly from sufficient time in treatment—theirs is not a hopeless case.
“Thirty days of residential really does have a significant impact,” says Siobhan Morse, director of research at Foundations Recovery Network, which has conducted extensive post-treatment follow-up with its patients in order to demonstrate that mainstream residential care produces results in this population. “In our research, as-usual treatment led to significant improvements at six months [post-treatment].”
This observation about the duration of treatment represents the profession’s biggest hope as well as its deepest fear going forward. Treatment leaders wonder whether residential care for anyone but the well-to-do will be feasible in the changing healthcare system. At the same time, they realize that more access to general healthcare in the way that it is now customarily delivered could result in more front-door prescribing of powerful opioids. They believe that would inevitably lead to more visits to addiction treatment facilities on the back end.
“The nature of reimbursement has driven the vast majority of doctors to spend far less time with people,” says Eric Collins, MD, physician-in-chief at Silver Hill Hospital in Connecticut. “When you have less time and you want to help someone, it takes much less time to write a prescription.”
Addiction and pain
The explosion of opioid prescribing for the treatment of pain has changed the face of many treatment facilities that once were known for treating addiction or pain but not both. The Father Martin’s Ashley addiction treatment center in Havre de Grace, Md., now also operates a Pain Recovery Program that in some cases accepts patients who do not fully meet criteria for addiction. During the design phase of its program, Ashley consulted with Mel Pohl, MD, FASAM, a high-profile proponent of opioid-free approaches to treating pain and the medical director at Las Vegas Recovery Center.
“There are few facilities that really understand the nuances of co-occurring pain and addiction,” says Pohl, author of several books on pain issues including A Day Without Pain.
Pain complaints had been escalating in Ashley’s overall treatment population for some time, so the organization went about establishing a focused program that pays equal attention to medical and behavioral health factors in evaluating and addressing pain. “We had to look at how people got here in the first place,” says Carol L. Bowman, MD, who directs the Pain Recovery Program.
Or, as Pohl says, “Until we deal with the emotional aspects of pain, we’re never going to get people better.”
Ashley’s program has a present capacity of eight patients and could eventually be expanded to double that. Patients stay for at least four weeks, and the professional staff agrees that five weeks is probably ideal.
The program uses no opioid medications for maintenance (it does employ a buprenorphine detox protocol), but relies on a variety of approaches that for all patients includes cognitive-behavioral therapy but for many also includes non-addictive medications, supplements, acupuncture, fitness activity and experiential therapies, among other interventions. The goal becomes one of improving patients’ coping skills and changing their perceptions of pain, not “curing” pain.
“When patients come in, we ask them what they have found helpful to address their pain,” says Peter Musser, PhD, a staff psychologist in the program. Often they will say that nothing has helped, though it’s possible that some options weren’t tried for long because of the effort and time involved.
The latter point represents a concern among addiction professionals about how physicians typically address pain: A medication represents less of an effort for the patient than something like a diet change or exercise regimen, and therefore tends to be the first option chosen.
Professionals with Ashley’s Pain Recovery Program also find that they often have to break through feelings of mistrust in the healthcare system that have built up in many of their patients, says Musser. “I’m a big proponent of getting collateral information, from folks at home, folks at work, perhaps workers’ comp,” he adds.
Ashley’s program appears to be generating promising early results: Two of the first four patients to go through the program recently reached their one-year anniversary successfully.