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Counselors are split on medication-assisted treatment

October 12, 2013
by Shannon Brys, Associate Editor
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How do counselors feel about the role medication plays in the treatment setting? Are they resistant? If yes, why?

This was the discussion at an afternoon session of the NAADAC (National Association for Alcoholism and Drug Abuse Counselors) conference today. The session, titled “SUD Counselors on the Job: A Bi-Directional Workshop on New Data on Job Satisfaction and Utilization of Medication-assisted Treatment,” illustrated data from the National Treatment Center Study (NTCS).

These were longitudinal studies of organizations that were privately funded, publicly funded, alcohol-focused or CTN (Clinical Trials Network) participants. The studies did not look at methadone clinics or detox-only programs.

The studies asked about specific medications including buprenorphine, naltrexone (tablet or injection), disulfiram, and acamprosate, as well as general questions about medication-assisted treatment. Results showed that the primary predictors of higher ratings of effectiveness and acceptability were specific training about the medication and use of the medication in the current treatment center the counselor was working in. Similarly, those counselors whose supervisors supported the use of medications in treatment reported higher points towards the idea as well.

Some aspects that negatively affected individuals’ attitudes about medication-assisted treatment seemed to be 12-Step orientation and the counselor being in recovery themselves. On the flip side, it was found that the higher the education level and tenure in the field, the more positive the attitude about medication-assisted treatment.

The floor was opened to discussion after the presentation of the data to find out what the counselors in attendance had to say about this form of treatment. One attendee said when he worked in treatment centers with psychiatrists who were knowledgeable about Suboxone and how it works, aware of proper administration, and able to train counselors, the counselors in those settings were in favor. However, after leaving that community to go into private practice, he now finds that psychiatrists are handling Suboxone treatment in their offices but have little to no information about it.

Paul M. Roman, PhD, the presenter of this session says he has heard many times of physicians prescribing Subutex, usually because it’s cheaper. He says this is more dangerous because it’s “like a live opiate.” He says many people who are on Buprenorphine do not want this on their insurance even though insurance will cover it, because they believe it will give them a record that will ruin them later on.  “And they may be right,” he said.

He also said it’s hard to find any research that has been conducted regarding medication-assisted treatment. “If you go to NIDA and ask what the evidence-based practices are for counseling to provide in association with buprenorphine treatment, they haven’t done the research. It’s not a priority.”

An attendee who teaches a substance abuse course at Georgia State said she talks to her class about opiates, naltrexone, buprenorphine and then shows them a film about legal heroin clinics in Europe.

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Shannon Brys presents an excellent review of factors contributing or inhibiting use of medications for substance use illnesses and I will add a few comments.

The National Quality Forum (NQF) utilizes a consensus process to develop standards for the treatment of physical illnesses. They have released 10 standards for the treatment of substance use illnesses. Four of the 10 focus on offering medications for detoxification, opiates, alcohol and nicotine that highlight the perceived importance of using medications as a component of treatment. While these are titled “voluntary” standards, the aim is to encourage payers to not provide contracts or reimbursements to organizations that do not implement these recommendations.

Paul Roman, who presented the workshop discussed in the article, also serves as the editor of an e-journal, The Bridge, published on-line by the national Addiction Technology Transfer Center (ATTC). A recent edition focused on the role of patients and family members in promoting the use of medications. Following publication, a TweetChat was held by members of the editorial board, ATTC staff and readers. One focus of the discussion was on the probability that malpractice lawsuits will likely be filed against organizations and their clinicians that do not offer FDA approved medications for substance use illnesses or a referral to a prescriber or organization that can provide these medications. A parallel can be drawn to a physician who diagnosis hypertension but does not inform their patient that medications are available that may assist in lowering their blood pressure or offer a prescription. If harm subsequently occurs with these patients, the medical record leaves a trail that will likely result in a successful lawsuit and difficulty in obtaining ongoing liability insurance.

We also discussed using the term “medication assisted recovery” rather than medication assisted treatment as the former may be more reflected of the field’s orientation.

On a side note, I endorse the NQF use of the term “substance use illness” and encourage our field adopt this terminology rather than “abuse” or “disorder”. Leadership could be provided by NIAAA, NIDA and SAMHSA in changing their names.

Andrew D. Bennett, CADC II, asked if I would also direct your attention to his article on this topic. In 2011, he wrote, "The drug-free treatment model is worth defending, now more than ever."

http://www.addictionpro.com/article/voice-wilderness

MAT was first used to describe treatment with methadone. It is now used more broadly to include all medications approved for the treatment of addictive disorder. MAT was controversial and rejected in the past as it was viewed as a synonym to use an addicting drugs. The bias against medications goes back to the time when highly addicting drugs like morphine, heroin, cocaine,LSD,benzodiazepines etc. were touted as cures. One school, strongly associated with the treatment of alcoholism was to reject all medications irrespective of their effectiveness or safety. As a result less than 10% of patients with alcoholism are offered MAT. One the other hand, the treatment of addiction to opioids is dominated by addicting and abusable drugs like methadone and buprenorphine.

The advancement in the understanding of the neurobiology of addictions has led to the development of highly effective and yes, non-addicting and non-abusable drugs. The first was naltrexone (not to be confused with naloxone)which was initially approved to prevent relapse to heroin use and later for the treatment of alcoholism. This medication is available as a daily pill or a monthly injection (Vivitrol). The other non-addicting medications include acamprosate and nalmefene. There are at lest half a dozen medications that look promising and all are non-addicting. I doubt if the FDA will approve another addicting and abusable drug after buprenorphine for the treatment of addictive disorders.

MAT is only part of the treatment. It is essential in the detox process and as an adjunct with counseling and other therapies for successful outcomes. MAT significantly increases patient involvement in treatment retention and long-term recovery. No chronic illness was ever successfully treated without an integrated approach.

By embracing MAT, we offer patient treatment choices and significantly enhance success rate. History has show that the stigma for a disease can only be removed through better outcomes. MAT is a vital tool to achieve better outcomes.

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Shannon Brys