The treatment system is failing opiate addicts

Doha15Stories like this are getting a lot of attention lately:

State Sen. Chris Eaton is planning to introduce legislation to encourage opiate treatment providers and doctors to break with an abstinence-based model and embrace evidence-based practices for treating addiction, the Minnesota Democrat told The Huffington Post.

I want to make it clear that I know nothing of Senator Eaton and am not questioning her motives.

If this was really motivated by a desire to spread evidence-based treatments, there’d be another, more interesting debate brewing.

That debate would be whether Senator Eaton should introduce legislation requiring that Physician Health Programs (PHP) start treating addicted health professionals with maintenance medications.

I doubt Senator Eaton wants that. I doubt she even knows much about Physician Health Programs. Her source of information about opioid addiction treatment was the Huffington Post article that painted abstinence-based treatment as hopelessly anti-evidence and ineffective while painting maintenance medications as THE answer to this problems that’s been with us for ages.

Why would she want to change opiate addiction treatment for the general population, but not for doctors? Because the treatment system for the general population is failing addicts and their families while the Physician Health Programs are producing outstanding outcomes.

Is the difference that one is abstinence-based while the other uses maintenance medications? No.

The difference is that PHPs get treatment and recovery support of an adequate quality, intensity and duration while the general population does not.

Debra Jay identified 8 essential ingredients in PHPs:

  1. Positive rewards and negative consequences
  2. Frequent random drug testing
  3. 12 step involvement and an abstinence expectation
  4. Viable role models and recovery mentors
  5. Modified lifestyles
  6. Active and sustained monitoring
  7. Active management of relapse
  8. Continuing care approach

PHPs provide treatment, recovery support and monitoring for up to 5 years and 85% of participants have no relapses. Of the 15% who relapse, most of them have only one relapse over that 5 year period.

Will maintenance medications improve treatment for the general population? It’s hard to imagine they will when they have the same retention problems that abstinence-based treatments have. Further, most of the treatment delivered with maintenance medications suffers from the same problem as abstinence-based treatment– inadequate quality, intensity and duration. (By duration, I mean the accompanying behavioral support as well as retention on the medication.)

So . . . this solution really focuses on the wrong problem.

The problem isn’t that treatment is abstinence-based. The problem is that abstinence-based and maintenance treatments too often do not provide adequate quality, intensity and duration.

So, why advocate to spread access to a treatment we won’t use on addicted physicians rather than spread access the gold standard of care that addicted physicians receive? That’s the danger of advocacy journalism that is dressed up as objective reporting.

I’m grateful to work in a place the works so hard to increase access to treatment and recovery support of an adequate quality, intensity and duration.

6 Comments

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6 responses to “The treatment system is failing opiate addicts

  1. Terry Newton

    This rebuttal should be sent to Senator Eaton. I agree that she probably knows little about the differentiation in treatment modalities of medical professionals versus the general population that receives band-aids rather than comprehensive care.

  2. Tim Gammons

    Hi, I feel compelled to respond. Jason I have huge respect for you guys at Dawn Farm and you guys are right on the money about so many things. I love what you guys do. Believe me we’re in lock step about everything involved with treating addiction except this. Buprenorphine can be part of a treatment plan that produces good outcomes. The above article omits this fact. OK now here’s the part where I say that yes I’m a doctor and yes I prescribe bup and yes I make money from prescribing bup and yes I speak for 2 of the pharma companies that make bup and yes they pay me for speaking (I also speak for Alkermes which makes an intramuscular naltrexone injection which is not bup and yes I use that drug, too). So if anyone wants to insist that because I prescribe and speak on behalf of bup products that I could not possibly ever have a credible opinion about because I’m just a paid shill for bup… Well here’s your chance to tune out. But I do have a credible opinion about this drug and I’ve been prescribing it since pretty much the day it hit the market 13 years ago, in both inpatient and outpatient settings. I’m still intrigued by the fact that it is such a polarizing drug (proved by the article above) and creates such visceral unyielding opinions in people. I believe this is unnecessary. The drug has some benefits when used appropriately, but it can also be abused. Either scenario has very little to do with the drug itself and everything to due with the person using it. I am a Board Cert Addiction doc, so I’m unfortunately in the minority with this but I offer group counseling in my Royal Oak office and give patients a ton of guidance regarding psych/soc support and behavioral change. In addition to group I have videos online, I have a bunch of written guides that patients receive and I tell people that clinically the best thing I see work for people is digging into the big book & doing all 12 of those steps under direct sponsorship. And I know you guys at Dawn Farm do the same thing. But unfortunately we see only a minority of patients do all this stuff. And why? Because it’s really time consuming, it requires tremendous willingness, a lot of work that wouldn’t be considered particularly glamorous, and a whole lot of patience because we’re taking about real, legitimate change to the core of who we are and that ain’t happening overnight! So it couldn’t be any more obvious why most people don’t do the stuff because human nature says let’s find a shortcut. And even the most successful recovering heroin addict who’s doing everything right, they also looked for shortcuts and failed & relapsed probably dozens of times before they realized there are no shortcuts and finally dug in & did the work to succeed in recovery. So how does this relate to your article? Because all the stuff you cite from Debra, it’s obvious to those of us on the front lines that all that stuff should be in place, and I as a guy that prescribes bup use a treatment model that includes all those things for pretty much all patients. Whether or not they use bup is irrelevant! Why would it matter? We tell patients to do what works and those things work! But they only work when…. Drumroll please…. When people actually comply with doing the stuff! And some patients on bup do all that stuff but most don’t. Which is the same as patients not on bup! Some patients not on bup do all that stuff but most don’t. So again it has not a whole lot to do with bup and everything to do with the patient. You know as well as I do that at Dawn a ton of people drop out & relapse. So do we have to blast Dawn Farm as a crappy place like some people want to blast bup as a crappy drug? Of course not, Dawn works great for those that are ready to do the work & not so hot for those that aren’t. Kinda like bup. Now how does this relate to HPRP? Well again kind of an obvious point you left out… HPRP patients have a medical license hanging in the balance! Most people with medical licenses kinda like having medical licenses. It helps them do things like pay their bills & feed their kids. So they have a real big incentive to walk the line and yes about 85% do. But once that HPRP contract is up compliance rates decline. I’ve been an HPRP provider for years, it’s a wonderful program, I love being a part of it, it’s and honor and a privilege. But HPRP patients have to spend a lot of money on their treatment, they have restrictions built into their work life such that they can attend their programming. So applying this treatment model and expecting this level of compliance with programming for the common working class man (or woman) is probably not realistic. And I really have to challenge this notion that it’s somehow an outlandish kooky notion to have a doctor on bup and practicing medicine… Why on earth would this be unacceptable? I personally have attorneys, teachers, an editor of a newspaper, business executives, small business owners (the list goes on) on bup. They function great, no job jeopardy, no relapses, they fulfill roles & obligations in all aspects of their lives. I know of a doctor that is on bup (not my patient but he’s talked to me about it). And guess what all these stable productive non-relapsers do while they’re maintained on bup? The same thing your stable patients do that are not on bup… They engage in psychosocial support and behavioral change, they have big books, they use the principals of the steps. So again, patient dependent not bup dependent. Now please anyone out there don’t pretend that I think bup is a perfect drug, I see it’s imperfections very clearly. There’s a lot of downside to bup, but the cold hard fact about this whole topic is that there’s a lot of downside to being an opiate addict. It really is just a horrible place to be, opiate addiction I believe should be recognized clearly for what it is, it is a brutal place to be, just so profound. Recovery is so much work & for those that do it I just have the absolute highest respect. It is so wonderful to see, as a doctor I just love being a part of it, I have so much respect for my patients who do this. And yes I will absolutely say the ones that do it via an abstinence based model are a little sweeter because I see them endure the discomfort of withdrawal and fight through it without relapse which is a rare and wonderful thing. But I felt compelled to point out some facts about bup and I caution people to have such strong opinions about buprenorphine, either to the bad or the good. It need not be so polarizing.

    • Tim,

      I’m pretty upfront about my bias against the push for maintenance medications. However, I don’t see this post as the anti-bupe screed you seem to.

      This post frames abstinence-based treatment as too frequently failing addicts.

      I go on to suggest that treatment programs providing maintenance medications suffer from the same problems.

      I do frame PHPs as the gold standard, but I emphasized their intensity, duration and quality, only mentioning that they are abstinence-based.

      The only strong opinion I meant to express was against the articles that oversold maintenance meds and presented inadequate treatment-as-usual as representative of the potential of abstinence-based treatment while ignoring PHPs and other effective models. These articles referred to bupe as a “wonder drug” and the distorted reporting is now inspiring legislation.

      All along, I’ve made it clear that I don’t want to interfere with access to meds, if they are what the patient wants. I just want all clients to have the opportunity to choose the same care a doctor would get.

      My points are supported with links to posts and studies.

      Best,

      Jason

  3. “So applying this treatment model and expecting this level of compliance with programming for the common working class man (or woman) is probably not realistic.”

    Why is it not realistic?

    Because it’s expensive and requires commitment from the patient and the system?

    Do we take that approach with cancer?

    People get medical leave during the intensive phases of treatment, they might get adjusted work schedules to get infusions, we continue to find ways to make treatments more tolerable, compliance easier and we expect funding for effective treatments. And, they provide monitoring and re-intervention for at least 5 years. Why should addiction be different?

    Besides, it doesn’t have to be that expensive, as I’ve outlined here: https://addictionandrecoverynews.wordpress.com/2011/11/11/too-expensive/

    Would we be able to get good compliance? I don’t know. (And, my point was that we’ve got big compliance issues with both treatment approaches.) No doubt, PHPs have a big stick and carrot. If we had a system focused on long term engagement and support, could we borrow from PHPs and find ways to better use identity, purpose, meaning and peer networks to keep patients engaged? I bet we could. However, we’ve never tried.

    • Tim Gammons

      Jason first let me say that this is such a great dialogue & I applaud you for having this blog and providing a stage for discussion about recovery. To address your question “why is it not realistic?” It’s not realistic because most people don’t show up. That’s the reality that guys like me & you, two guys on the front lines treating real world patients face. People stop doing what we expect them to do. HPRP has an inherent incentive for the patient (their medical license) that improves compliance. And this is not a bad thing, I have seen a whole bunch of medical professionals come kicking & screaming into the program and only because HPRP throws the hammer down on them do they show up for all their programming and guess what? Low & behold they figure out they have a big time problem and they in fact do benefit from recovery. And it’s only because there’s no wiggle room in HPRP that they show up & do the work & somehow something clicks and they realize that hey my ego and resentments and self-centered fears and insecurities and failed relationships and conflicts with others (I could go on & on…) maybe these things are the real issue & there’s a solution to this stuff & when I do the stuff it works & I feel better!!! What a concept! So then they start doing the stuff because they feel better and not because of the HPRP hammer & they stick with it one day at a time for the rest of their lives because they’re happier. But these people confide to me that if HPRP didn’t throw the hammer down initially and restrict their medical license & hold it in the balance which forced them to show up that they never would have heard the “click” & the light never would have gone on. Now it doesn’t always happen this way, but sometimes. And really Jason it’s the same thing we see with the court-ordered regular Joe who walks the line while on probation but relapses after their legal obligations are fulfilled. It breaks our hearts, we just hate seeing it, but it happens. How many times have you heard “Doc I can’t believe I’m saying this but getting arrested was the best thing that ever happened to me.” They are incentivized to comply with treatment due to the threat of prison, etc. But in the real world everyone does not have a medical license hanging in the balance or the threat of incarceration so there is an inherent wiggle room and the fact is we see a significant percentage of people stop showing up because they just don’t want to show up. So there is a real danger in my opinion to pretend that a treatment system, or treatment model or approach, or an insurance company or adminstrator, or a therapist, or a doctor, or a treatment facility, “fails” the addict. Will there always be room to tweak & improve all of these things? Obviously yes there will be, and that’s why dialogue like you’ve initiated is so awesome. But the fact is the addict fails the addict. The addict is not the victim of a failed system that has failed them, I just absolutely loathe the victim card in early recovery, it’s just so toxic and it’s I believe a real important part of early recovery, accountability, focus can’t be on some perceived system that has failed the individual. And these are all aspects of treatment that have nothing to do with whether patients are on bup. These things work for everyone, bup or no bup. It is counterproductive to focus on bup the stuff that works which is the behavioral change, the long-term consistant effort required. When people do this stuff that works, people get better, people feel good. It works for bup maintained patients and for abstinence based patients. It is important to know that in the opiate tolerant patient using bup correctly (appropriate dose, no benzodiazepines, no amphetamines, etc) there is no reason to believe it is legitimately mood or mind altering. It is simply a unique and overall manageable opioid that is intended to alleviate the discomfort of opiate withdrawal. The conundrum is how to get people to comply with real treatment. Bup is not real treatment, it’s just a substance, all substances have limits. Begavioral change, our actions and attitudes, our internal growth… These are limitless. So how do we get people to stick with long-term residential and recovery mentors and keep working out of the big book & all the other great stuff that Dawn Farm recommends (you do a great job from what I’ve seen emphasizing the importance of long-term residential which I believe is just vital) and guys like me recommend? I don’t know that there is anything realiable to produce this willingness except the gift of desperation. No treatment model could ever produce the kind of willingness it takes to succeed in recovery. How could we ever even expect it to? To be sustained beyond HPRP or beyond probation, it obviously has to come from within, it has to be the top priority in the recovering persons life because it’s so hard in early recovery & so easy to quit that people only stick with it when they perceive it as a matter of life or death (perhaps we’ve heard something about ‘hitting bottem’ a time or two?…). So is this a bad thing? Does this mean that since recovery is so much work & such a small percentage of people do it that what’s the point? Why do we even try to devise treatment models at all if compliance is so poor? No of course not! Even though it’s a small percentage of people that succeed it’s still a lot of people! And the ones that go on to have long-term success, wow the rewards for this can’t be described with words. And I believe there is an inherent beauty in the work that is required for success in recovery. It’s not about having a system to plug into. The willingness and the work, the patience required… The pain of the process, the reward at the end, the truths uncovered are things of great beauty. It is just stunningly beautiful to it’s very core. It’s pretty darn rare, though, no short cuts, and it can be brutally painful. And that’s what gives recovery it’s stunning beauty.

  4. I very much apprecaite this dialogue. On line and in social media we see so many extremist views. All approaces can work and do work and work better when people follow the suggestions. What Im concerned about is when we see people who can significantly effect the field on a large scale call maintaince “the standad of care”. To me its one of many types of care and if one really worked better than all the others we’d have a different conversation. Instead like with depression and obesity there need to be many options and most peope use a combination of things over time so it isnt either/or. I appeciate hearing from quality prescribers who also offer tx and other recommendations such as AA/NA to engege cl in recovery. Unfortuntaly many sub clinics are not doing that and the incentive to keep someone on meds for many many years and not refer them to other resources too is concerning.