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Today's addiction treatment is an evolving practice

February 3, 2015
by Julie Miller
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Over the past decade, illicit drug use has steadily increased, meanwhile, the standard of care to treat addiction remains a continuously evolving practice that dates back centuries. Presenting at the Addiction Professional Academy in California, Benjamin R. Nordstrom, MD, PhD, Diplomate of the American Board of Psychiatry and Neurology and assistant professor at Dartmouth-Hitchcock Medical Center, provided a comprehensive look at how opioid addiction has evolved and how providers are responding to emerging patient needs.
Medication-assisted treatment has become an effective tool, but Nordstrom stresses that it can never supplant the behavioral counseling that is critical for recovery.
"These drugs are drama reduction agents," he told the audience of addiction treatment providers. "You guys are the treatment. The medication, all it does is buy time so the patients can listen to you without their minds going in a hundred different places."
Nordstrom described the pharmacological distinctions between full agonists (methadone), partial agonists (buprenorphine) and antagonists (naloxone), and how each attaches to mu opioid receptors and interacts with the brain's mechanisms. But Nordstrom also pointed out that clinicians need to be as meticulous as possible with the comprehensive care plan to optimize the medication's effectiveness for each individual. 
For example, he said, methadone as it attaches and activates receptors, has increasing effects on the brain as the dose increases.
"The most abused opioids are the full agonists," Nordstrom said. "They are the race cars. The more you press down on the pedal, the faster you go."
He also compared buprenorphine to a slow-moving truck: at some point it just won't move faster no matter how hard you push the accelerator. Less of a maximal effect is achieved. 
"There's a flat effect with buprenorphine around 16 milligrams--a ceiling effect where you don't get more bang for your buck," he said. "And people really feel the difference."
Additionally, there's naloxone, an antagonist, which binds to the receptor but its distinction is that it does not activate the receptor. Nordstrom compared it to an unmoving object that might be used to block off a parking space. The antagonist doesn't allow the vehicle to go anywhere. 
"It doesn't turn the system on," he said. "It blocks the spot."
As for how long a patient should remain on maintenance drugs, Nordstrom said the science is lacking. Patients who taper off medication-assisted treatment cycle out of the programs and there aren't any mechanisms to follow their long-term recovery.
"It's an embarrassment that we don't know how long to keep people on maintenance drugs," he said.
Complicating factors
In addition to choosing the best-suited medication and dose for each individual, clinicians need to be tuned in to the influencing factors in a patient's life, such as compliance with outpatient programs, distance to a clinic or treatment center and the home or family situation.
Nordstrom challenged the session attendees with several case studies of patients he treated in his clinical practice, asking clinicians what they might do given each situation.
For example, there was the case in which Nordstrom and his team believed a patient was diverting maintenance medications. The young woman claimed to be robbed on the street and had lost her written prescription. She called the clinic and asked for a new prescription. Here, the best course of action was to call the patient's pharmacy and find out if there were any records of multiple fills. Clinicians suspected she was selling the prescription drugs, and the pharmacists confirmed that they had their suspicions as well.
In the case study, the woman was referred to residential treatment but refused. Ultimately, clinicians released her from treatment entirely.
Nordstrom said it's not a clinician's duty to confirm diversion "beyond a reasonable doubt," but there is an obligation to do what is best for the patient. In this case, the patient was not complying with treatment and new prescriptions could have led to worsening outcomes.
"We will try you if you try," Nordstrom said of noncompliant patients. "But if you do not try, we will not try harder than you."


I like the automobile metaphor for opioid MAT. But I couldn't help but wonder, why are they still writing out paper prescriptions? Especially to people with SUD or in recovery? You'd think they'd call it in. Is that setting people up for possible failure? Just some thoughts.