By necessity, many of us in the addiction treatment field have developed some special expertise in the management of opioid dependence over the past five years. An opiate epidemic is sweeping our nation, with some states hit particularly hard. Ohio has been one of those states.
Since 2009, annual deaths in Ohio from unintentional overdose (usually involving opioids) have exceeded the number of deaths occurring on our highways. Four people (most under the age of 30) die every single day in Ohio as a result of unintentional overdose. If four young people in Ohio died from meningitis every day, there would be an uproar of unimaginable proportions.
Our outpatient (Northland) and residential (The Ridge) facilities are both situated in relatively upscale suburban communities outside Cincinnati, Ohio. Over the past 10 years we have seen a steady increase in the number of people seeking help for opioid dependence. Fully 60 to 70% of new patients identify an opiate as their drug of choice. This represents a complete reversal of our patient mix of 10 years ago, when most patients seeking help were primarily abusing alcohol.
In addition, most of our patients abusing alcohol typically are over the age of 40, married, have children, and are gainfully employed. Conversely, most of our opiate addicts are under the age of 30, single, in a relationship with another user, living in a substance-promoting environment with limited or aborted education, and are unemployed or have limited employment opportunities.
To complicate matters further, most of our young opiate addicts, in the months prior to admission, have undergone a rapid escalation of their disease and suffer a rather severe deterioration in global functioning.
Most have started with oral opiate prescription medication (often from family members, friends or the handy medicine cabinet) but have progressed to the use of heroin by either snorting or the intravenous route. Heroin is readily available in the community (even to high school and college students) and is relatively inexpensive compared to the oral counterparts. It is also intensely addicting, and approximately one of every four people who experiment with heroin becomes dependent. The sharing of needles and straws is common, and approximately half of our patients who have shared a needle test positive for the hepatitis C antibody.
Shifting the approach
Another unfortunate fact is that the traditional treatment approach for opioid addiction (abstinence pathway plus education, group counseling, and a 12-Step program) has a low success rate. Despite recent advances in medication-assisted treatment (MAT), many programs around the country cling to the abstinence pathway as the only treatment modality offered.
We welcomed Hazelden’s recent announcement that it will now utilize buprenorphine on a maintenance basis for selected patients. Data collected over the past two to three years clearly demonstrate improved outcomes with the use of medication-assisted treatment (40 to 60% one-year sobriety).
We suggest that MAT should be the standard of care in opiate addiction treatment today. Medication assistance helps retain people in treatment by suppressing or eliminating the opiate cravings that can persist for months after abstinence. Retention in treatment gives people the education and the time needed to make the changes in their behavior and environment that are necessary for long-term sobriety. Completion of treatment gives these people a fighting chance against this deadly disease.
The remainder of this article will summarize our four-year experience in a suburban population with the use of the Schedule III opioid partial agonist buprenorphine combined with the opioid antagonist naloxone (trade name Suboxone).
We use an aggressive approach to the treatment of opiate dependence. To be eligible for medication assistance on an outpatient basis, all patients must be willing to commit to completing our MAT program of 15-plus months. We do not provide “medication-only” care. To date, we have had no deaths among patients while engaged in treatment, and approximately 40% of our MAT patients go on to complete treatment.
Finally, I will address the two issues most often cited as the rationale against MAT: that it is only replacing one drug with another, and that buprenorphine is being diverted primarily for its euphorigenic potential.
All patients undergo a comprehensive alcohol and drug assessment by a licensed chemical dependency counselor on their first visit. Patients who meet DSM-IV criteria for opiate dependence, and who are interested in the MAT program, are then scheduled for a comprehensive physician-performed medical history and physical examination, forensic urine drug testing, comprehensive laboratory evaluation that includes testing for HIV and hepatitis B and C, and a review of the patient’s State of Ohio Automated Prescription Report (OARRS).
Patients are asked to remain abstinent for 24 hours if they have been using a short-acting opiate, or up to 72 hours or more if they have been abusing a long-acting agent, before meeting with the physician.
Before medication is administered, the physician reviews a “Buprenorphine Informed Consent” form with the patient, which specifically addresses the risks and benefits of taking the buprenorphine/naloxone combination. We also require a signed “Treatment Contract,” which clearly spells out the requirements for continued eligibility for medication, and the consequences of unacceptable behaviors—which may include the discontinuation of medication.
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.