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Towards an Integrated Model of Opioid Addiction Treatment

By Ross Fishman PhD 09/08/16

There is great controversy as to how long maintenance on buprenorphine-based drugs such as Suboxone should last and what is the best method of tapering.

Towards an Integrated Model of Opioid Addiction Treatment
Working together toward consistency.

The rise of Suboxone and other buprenorphine-based treatments for opioid-use disorders, along with methadone, have created an environment in which thousands of opioid dependent people are now able to receive medication-assisted treatment (MAT) for their disorder, and new federal laws will make it much easier for such individuals to find prescribers for their MAT. Dr. Ross Fishman reminds us that we are still in the early stages of MAT, and that there is no consistent formula for either prescribing buprenorphine or weaning people off of it. Additionally, many people receive MAT in private offices with little or no psychosocial treatments for addiction available. He contrasts this with a preferred treatment environment in which prescribers, counselors and therapists are all working together in one integrated model of treatment for opioid use disorder…Richard Juman, PsyD

I am increasingly astounded at what I see as a major disconnect among addiction professionals as they offer approaches to treating opioid misuse from opposite sides of the elephant. I believe they need to collaborate to provide a relatively unified, comprehensive approach. There are several ways this can be accomplished.

First, it is necessary to acknowledge the growing concern as opioid use and opioid overdosing appear to be spreading across the country, though mainly clustered in certain areas. The news is awash in statistics and opinions about the growing problem of prescription drug misuse, heroin misuse, the overdose deaths attributed to both, the increasing presence of fentanyl in bags of heroin and the lack of accessibility to treatment. There are various opinions to address the problem from how the larger society (national drug policy, law enforcement) should respond, down to how families can deal with the heartache of coping with the users in their lives if not right in their homes.

Initially perceived as a problem for minority communities, opioid overdoses have spilled over to the non-minority population in increasingly alarming numbers. It has taken this shift to arouse the public and law enforcement to reframe the solution from one of incarceration to treatment. This is a valuable shift in reaching opioid users who, as someone said, are not good people who are bad but sick people who need help.

Despite the longstanding vilification of methadone—a valid and medically proven assisted treatment for heroin addiction—and the recent expressed reservations about the increasing use of buprenorphine (Suboxone, Zubsolv) as an alternative, their availability and proper use make for the most effective treatment approach, physiologically and psychologically. Nevertheless, the ongoing misunderstanding of the nature of opioid addiction—its long-term impact on the structure and function of the brain and the psychological impact on the user—continues the groundless argument that these medications are “just substitutes.”  

It is a fact that both methadone and buprenorphine are narcotic medications and that switching to them maintains a physical dependency. This is anathema to the many people who selectively misperceive the concept of social dependency, in general, and drug dependency, in particular. The only acceptable goal from their perspective is immediate and total abstinence. Reducing any substance use over time is rejected as a form of controlled use which is doomed to fail.

Whether the conversation is about alcohol, marijuana, cocaine or opioid use, it is certainly a truism that less use is better and no use is best. As a harm reduction strategy, that idea holds for all substances. When it comes to opioid addiction, however, there are unique features about it, in contrast to the other addictions, that make it a horse of a different color.

As anyone in a relationship comes to know, when there are disagreements between people, it is best to think carefully about picking your battles. With respect to opioid addiction, the battle is between:

  1. Maintaining a person on a dependency that can remove the elements of illegality, antisocial behavior, inability to keep a job or stay in school, and inciting emotional upheaval in the home, and
  2. Dealing with the very high probability that the user and the significant others will face the consequences of recurring relapses in the days, weeks, months or years after “stopping.” 

I have written elsewhere that one unrecognized but ultimately ubiquitous goal of human behavior is to reduce harm. It is the mantra of the medical field. It is the mission, strategy and goal of every parent raising a child. It is the goal of anyone trying to stop smoking, do more exercise or eat healthier. Falling short of these goals, as is often the case, is frequently taken in stride. When it comes to ourselves, we are very understanding of how difficult it is to make the necessary changes and maintain them as part of an overall healthier lifestyle. “Oh well, I’ll just start over again next _______ .” (Pick your favorite time interval). When it comes to substance use, however, we tend to be unforgiving, not willing to accept the user’s shortcomings as parallel to our own.

We readily accept the need for the lifelong medically-assisted treatments for diabetes, heart disease, hypertension, arthritis, asthma, HIV and other, lesser known, disorders. These conditions call for a continued dependence on the prescribed medication in order to maintain a person’s functionality. In fact, it’s the same way with opioid dependence. Individuals who follow the prescriptive guidelines and are serious about getting their lives “back on track” do marvelously well in everyday life. Furthermore, when they follow the guidelines, they look, behave and function daily in ways not significantly different than other people. I do not intend to imply too rosy a picture. There are indeed, individual differences among opioid dependents—but not necessarily different from those variations seen in the non-user population.

Being maintained on methadone or buprenorphine raises the frequently asked question of how long it is necessary to remain on them. There are different perspectives. One extreme but viable option is to never go off them, just as with the medical conditions mentioned earlier. Methadone has been available for over 50 years and outcome studies have shown few long-term negative effects, despite the anecdotal reports from and rumors by methadone patients. Many evaluate their methadone experience without considering the other lifestyle choices they have made that may account for the symptoms they attribute to methadone.

To date, there has been little, if any, research on the long-term effects of buprenorphine—unfortunately, manufacturers, who have been criticized for not conducting them, seem to be in no hurry to do so. Physicians I have spoken with or heard at addiction conferences do seem to prefer using medically-assisted treatment with buprenorphine for some limited period of time, though there appears to be no consensus on how long. In the end, individual differences among patients and their environments prevail. Our physician would allow patients to remain on buprenorphine indefinitely if that is what the patient wants, and the new law will make that easier.

There is great controversy as to how long maintenance on buprenorphine should last and what is the best method of tapering. One thing is clear. It is dangerous to stop using buprenorphine or any opioid suddenly. The inevitable withdrawal may not be life-threatening, but it can be excruciatingly painful. The greater danger occurs when the user, whose tolerance for the usual dose of opioid drops after a period of abstinence, relapses and mistakenly uses the same amount of drug used before stopping. With a lowering of tolerance, the higher dose too often results in passing out and enough respiratory depression to prove fatal. A user, if alone, stands little chance of survival. If they're not alone, the user is at the mercy of others, as they may not consider that what is going on internally may be more than just “sleeping it off.”

How then, to taper? In methadone clinics, the reduction process is guided by the clinical experience of the medical staff but determined in collaboration with the patient. Although there may be differences in protocol from one methadone program to another, after more than 50 years of experience, the differences may not be significant. 

With regard to buprenorphine, however, there is no established protocol. Physicians who prescribe often work independently. There is much face-to-face and Internet-based communication among buprenorphine-maintained individuals who, based on their own experiences, will recommend the “best” way to proceed. Some argue that tapering is extremely difficult and state that it is more difficult than moving off methadone. Even among physicians who have been prescribing buprenorphine for years, there is great variability in tapering strategies. Recently, in a report on The Fix, a patient complaining of a poor sense of well-being while on a low dose of buprenorphine reached out for help. Several recruited addiction “experts” responded.  Some recommended a reduction of the current dose while others recommended an increase. In fairness, the responders correctly suggested that other factors may be contributing to his symptoms, and advised him to work with his physician to address his issues.

I am aware of several physicians who have developed well thought-out schemes for tapering off buprenorphine. Although there were differences among them, there were a few common elements.

The most important ones are that:

  1. When properly done under medical supervision, it will take a long time—many, many months to a year or more, and 
  2. There will be individual differences among patients that require the tweaking of any strategy to meet those individual needs.

The disconnect I referred to earlier is between the prescribing physicians and the substance use disorder professionals—psychiatrists, psychologists, social workers, mental health counselors and addiction counselors—who attend to the psychosocial aspects of people seeking recovery.  

The majority of patients in my clinic previously receiving buprenorphine from private physicians reported that they were given monthly prescriptions with occasional or no urine testing and no referrals for counseling. The DATA 2000 guidelines recommend that the physician “should pursue a team approach to the treatment of opioid addiction including referral for counseling and other ancillary services,” and to the use of “urine (or other toxicologic) tests” to indicate that they “are free of illicit drugs.” Unfortunately, physicians are not bound by these guidelines that define complete or best practice. As a result, some patients are receiving a necessary, but not sufficient, component of treatment that can lead to effective recovery.

The substance use disorder professionals who focus on the psychosocial aspects of opioid addiction have for years been involved in developing treatment strategies that go beyond the “one size fits all” approach characteristic of 12-step philosophies that emphasize abstinence as the only acceptable means to a successful recovery. In the last few years, great effort has been made to educate treatment professionals and the public alike of the importance of addressing the psychosocial underpinnings of addiction, including an uncovering and understanding of earlier life experiences that contribute to the development of addiction and which, if not addressed, interfere with efforts to recover. Recent work has revived the client-centered counseling approach of Carl Rogers and the psychodynamic aspects of the psychoanalytic perspective. These elements have been brought together in what psychologist Andrew Tatarsky, PhD, and others have called “integrative psychotherapy” which incorporates a harm reduction approach. 

But I have not seen that either of these two major treatment groups—prescribing physicians and therapists—sufficiently acknowledges the other in discussions of how to treat opioid addiction. Tapering setbacks and full relapses can occur in the most disciplined patient on buprenorphine when a psychosocial crisis arises and becomes an overwhelming trigger to use. Conversely, a hard-working psychotherapy patient may relapse because a too large dose reduction of buprenorphine results in a withdrawal state that becomes too unbearable to withstand. 

The disconnect can easily occur when prescribers and therapists work in separate locations and do not readily converse with one another about their common patients. And patients, intentionally or otherwise, may use splitting by telling them different stories or by eliminating information that is best shared. To repair the disconnect, prescribers and therapists must work collaboratively—ideally they practice under the same roof, though this is unlikely in most cases. They should be in frequent contact so that physiological and psychological progress can proceed concurrently as much as possible. Increases or decreases in prescription doses should be discussed beforehand with the therapists to review the purposes of the change and to determine readiness. Therapists should be communicating to prescribers about significant improvements or when events occur in patients that may be putting them at risk for using.

Physicians working independently ought to refer patients for concurrent counseling. Our program, Innovative Health Systems, will provide counseling to patients who receive buprenorphine prescriptions from their private doctor. Frequent drug testing can be carried out by either party and the results shared. Feedback in both directions is easily accomplished after consents are signed.

Within Innovative Health Systems, our certified medical director and the counselors confer frequently. Toxicology results are shared, urine specimens are obtained before each medical visit and sometimes more than once a week. Initial prescriptions are limited to once a week for the first 12 weeks, then longer if the patient is showing progress toward treatment plan goals: attending specialized buprenorphine groups (usually two, but for some, three times a week), negative toxicology results, good attendance and participation in groups, and partaking of individual counseling sessions.

Treatment outcomes for opioid use disorders can be improved through an approach that comprises the medically-assisted benefits of buprenorphine and of harm reduction psychotherapy that focuses on both the developmental roots of drug-using behavior and the relapse prevention strategies and plans that strengthen the patient’s path to recovery.

Dr. Ross Fishman, a native of New York City, earned a B.B.A. from the Baruch School of Business Administration (CCNY). Full bio.

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Dr. Ross Fishman, a native of New York City, earned a B.B.A. from the Baruch School of Business Administration (CCNY). You can see his full bio, here. You can also find him on Linkedin.

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