Patients qualifying for MAT must attend our facility on three consecutive days for detoxification/induction, during which time we make a determination of the lowest effective dose of medication that will suppress withdrawal and cravings.
Most patients are stabilized on 8 to 16 mg of daily buprenorphine/naloxone, and this dosage is maintained throughout the intensive outpatient phase of treatment. We do not use plain buprenorphine tablets, except under direct observation by a nurse. We prescribe only the filmstrips, and not for more than one week at a time. (To our knowledge, thus far no one has figured out how to successfully inject a filmstrip.)
Patients must complete an initial 10-session intensive outpatient program designed by our staff specifically for patients recently started on medication assistance. Upon successful completion of this phase, they are then enrolled in our traditional IOP, which lasts an additional 8 to 12 weeks. This second IOP requires nine hours of attendance each week and is divided into two phases: a Beginners/Pre-Contemplative Group and a more advanced Action Group when they have met certain benchmarks of recovery.
Patients also must attend a 30-minute individual counseling session each week. A weekly progress report is prepared by the patient’s counselor and is provided to the physician prior to issuance of another prescription.
All of our patients are asked to attend a minimum of three self/mutual help groups weekly. During treatment all patients must also agree to random forensic urine drug testing and random medication counts. We also encourage all patients and families to attend a weekly three-hour family education group during IOP.
Patients who are struggling to remain sober are asked to attend an additional session (called the Treatment Assistance Group) each week. Patients who still are unable to remain sober, or are engaging in highly dangerous use, are referred to a higher level of care (residential).
Upon successful completion of IOP, patients must attend a weekly Aftercare/Relapse Prevention group in addition to continued individual counseling for a minimum of one year. During the aftercare phase of treatment, the dosage of medication is gradually reduced as the patient develops a stronger program of recovery. Almost all patients are able to come off of medication in 12 to 18 months.
We often hear from patients that they are told by Narcotics Anonymous (NA) attendees (usually the “old-timers”) that “medication is only replacing one drug with another.” This could not be further from the truth, and indicates a misunderstanding of the pharmacodynamics of the medication.
Our experience is that buprenorphine/naloxone does not result in a euphoric response in the opiate-dependent patient who has a significant tolerance to opiates. Although buprenorphine is “mildly reinforcing,” almost all patients report that they “just feel normal,” and can function fully without cognitive or motor impairment. They do not experience the daily highs and lows that characterize addiction, and they do not exhibit problems with control of use.
Although physiologic dependence does develop, our experience is that most patients can come off medication (when tapered appropriately) without any major withdrawal effects.
Finally, there is the problem of diversion. Most of our patients report that they have used buprenorphine or buprenorphine/naloxone off the street at one time or another during their active addiction. However, they report that their intent was not to get high (although they would have been fine with that had it occurred)—they took it to self-medicate their withdrawal symptoms when their opiate of choice was not available.
It should be noted that patients who are opiate-naïve, or who have lost their tolerance, may experience a significant euphoric effect from buprenorphine, particularly if they snort or dissolve and inject the plain buprenorphine tablet (buprenorphine without naloxone).
We believe the jury is no longer out on the issue of medication-assisted treatment for opiate dependence. The evidence demonstrates that the benefits of MAT outweigh the risks.
Jeffrey A. Stuckert, MD, is CEO and Medical Director of Northland (an outpatient facility) and The Ridge (a residential facility) near Cincinnati, Ohio. Dr. Stuckert is a Treatment Advocate for Suboxone (manufactured by Reckitt Benckiser Pharmaceuticals). His e-mail address is Jstuckert@theridgeohio.com.