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The opioid menace lives on: programs throw multiple approaches at an opioid dependence problem with significant staying power.

The names of emerging drug threats come and go, but for years now opioid dependence lias remained the most prevalent and puzzling issue being addressed and analyzed in the nations public and private drug treatment facilities. Some communities continue to battle a prescription drug misuse epidemic with no clear end in sight, while other locations have seen a resurgence of street heroin, and few leaders believe any other drug phenomenon stands a| chance of eclipsing the societal impacts of opioid addiction.

Just as there appears to be little possibility of declaring imminent victory against the opioid problem, so too does it seem unlikely that proponents of drug-free and medication-assisted treatment approaches will achieve a complete meeting of the minds anytime soon. While some traditionally 12-Step based facilities such as Hazelden have recently opted to allow some of its patients to receive maintenance dosing of buprenorphine while in residential treatment (see accompanying article on page 20), the movement in that direction has hardly been a groundswell to this point among the most influential treatment centers nationally.

On one point, members of both camps steadfastly agree: Opioid-dependent patients can benefit greatly from sufficient time in treatment--theirs is not a hopeless case.

"Thirty days of residential really does have a significant impact," says Siobhan Morse, director of research at Foundations Recovery Network, which has conducted extensive post-treatment follow-up with its patients in order to demonstrate that main-stream residential care produces results in this population. "In our research, as-usual treatment led to significant improvements at six months [post-treatment]."

This observation about the duration of treatment represents the professions biggest hope as well as its deepest fear going forward. Treatment leaders wonder whether residential care for anyone but the well-to-do will be feasible in the changing healthcare system. At the same time, they realize that more access to general healthcare in the way that it is now customarily delivered could result in more front-door prescribing of powerful opioids. They believe that would inevitably lead to more visits to addiction treatment facilities on the back end.

"The nature of reimbursement has driven the vast majority of doctors to spend far less time with people," says Eric Collins, MD, physician-in-chief at Silver Hill Hospital in Connecticut. "When you have less time and you want to help someone, it takes much less time to write a prescription."

Addiction and pain

The explosion of opioid prescribing for the treatment of pain has changed the face of many treatment facilities that once were known for treating addiction or pain but not both. The Father Martin's Ashley addiction treatment center in Havre de Grace, Md., now also operates a Pain Recovery Program that in some cases accepts patients who do not fully meet criteria for addiction. During the design phase of its program, Ashley consulted with Mel Pohl, MD, FASAM, a high-profile proponent of opioid-free approaches to treating pain and the medical director at Las Vegas Recovery Center.

"There are few facilities that really understand the nuances of co-occurring pain and addiction," says Pohl, author of several books on pain issues including A Day Without Pain.

Pain complaints had been escalating in Ashley's overall treatment population for some time, so the organization went about establishing a focused program that pays equal attention to medical and behavioral health factors in evaluating and addressing pain. "We had to look at how people got here in the first place," says Carol L. Bowman, MD, who directs the Pain Recovery Program.

Or, as Pohl says, "Until we deal with the emotional aspects of pain, we're never going to get people better."

Ashley's program has a present capacity of eight patients and could eventually be expanded to double that. Patients stay for at least four weeks, and the professional staff agrees that five weeks is probably ideal.

The program uses no opioid medications for maintenance (it does employ a buprenorphine detox protocol), but relies on a variety of approaches that for all patients includes cognitive-behavioral therapy but for many also includes non-addictive medications, supplements, acupuncture, fitness activity and experiential therapies, among other interventions. The goal becomes one of improving patients' coping skills and changing their perceptions of pain, not "curing" pain.

"When patients come in, we ask them what they have found helpful to address their pain," says Peter Musser, PhD, a staff psychologist in the program. Often they will say that nothing has helped, though its possible that some options weren't tried for long because of the effort and time involved.

The latter point represents a concern among addiction professionals about how physicians typically address pain: A medication represents less of an effort for the patient than something like a diet change or exercise regimen, and therefore tends to be the first option chosen.

Professionals with Ashley's Pain Recovery Program also find that they often have to break through feelings of mistrust in the healthcare system that have built up in many of their patients, says Musser. "I'm a big proponent of getting collateral information, from folks at home, folks at work, perhaps workers' comp," he adds.

Ashley's program appears to be generating promising early results: Two of the first four patients to go through the program recently reached their one-year anniversary successfully.

Foundations similarly does not use maintenance medication therapies for opioid addiction, although research director Morse says otherwise the facility tends to look at any interventions that it believes could improve the patient's quality of life. Foundations' research has tended to show that while its opioid treatment population might present with more ancillary problems (such as legal and family issues) than its other treatment clients, none of this appears to warrant establishing an entirely different treatment track for addressing opioid addiction, she points out.

"The research literature that's out there tends to address a public population with an over representation of higher levels of trauma, higher unemployment, and justice involvement," says Morse. "There is little research on the private population."

Morse adds that Foundations' group of treatment centers tends to see two distinct cohorts of opioid addiction patients: an 18-to-25 age range with more polydrug use and significant family/relationship issues, and a 26-plus group with a greater prevalence of concurrent medical problems.

Suboxone's impact

Up until 2012, Silver Hill Hospital would not admit patients who had been receiving maintenance dosing of Suboxone, the most commonly used formulation of buprenor-phine. Collins, a board-certified addiction psychiatrist hired at Silver Hill last year, went about the process of changing the culture of the organization to embrace all possible approaches to treating opioid addiction in its residential program, including maintenance medication. He had the blessing of the hospitals president to pursue this.

"I've asked all the medical staff to have an open, unbiased discussion about the value of maintenance therapies for opioid dependence" says Collins. "These are effective modalities to save lives."

Collins calls buprenorphine the most effective tool to emerge for combating opioid addiction in nearly 50 years, since the advent of methadone. Yet not all Silver Hill patients receive Suboxone or even want to, and Collins emphasizes that the residential program's integration of Dialectical Behavior Therapy (DBT) and the 12 Steps plays an equally critical role in the programs clinical success.

Silver Hill treats up to eight patients at a time who present with co-occurring pain and substance dependence. They stay for five weeks, and generally are either self-pay patients or are having their treatment financed by workers' compensation. He says of the latter system, "It has been willing to pay to get people off opiates."

Collins says the move to include maintenance medication in Silver Hill's accepted modalities did generate some anxiety among members of the clinical staff who don't equate this practice to a stable recovery, but he sees that attitude shifting as outcomes become apparent. "People are seeing that these patients are just as helped as others," he says.

He says insurance companies in his region generally will pay for the maintenance treatment, along with the needed medical visits and urine drug testing. He adds that Silver Hill's move to incorporate maintenance medication has boosted its standing in the addiction psychiatry community. "We've had more referrals," he says.

Much Suboxone prescribing of course occurs in solo or group medical practices, where Libertyville, III., physician Adam Rubinstein, MD, says it has revolutionized treatment. "People can remain with their family when receiving treatment; they can achieve their dreams," says Rubinstein, who with reality television personality Michael "The Situation" Sorrentino this year established a website ( to educate the public on issues related to prescription drug addiction and to share information about medication-assisted treatment.

Rubinstein says many of his patients use the word "miracle" to describe Suboxone, but he also points out, "This is one tool, along with counseling and support, that makes me empowered as a clinician."

He adds that there is no one patient profile for which Suboxone serves as the ideal treatment. As long as the patient is motivated, the medication can play an important positive role.

"The heroin injector is a more difficult patient to help," says Rubinstein, who has posts at Rush Medical College and the University of Chicago Pritzker School of Medicine. "Once they've graduated to this, their connection to their drug of choice is quite strong."

Forecasting the future

Addiction experts say much of the rise in prescription drug dependence was fueled by well-meaning physicians who believed that despite research evidence to the contrary, opioid medications would work to treat chronic pain since they were shown to be effective for short-term use. While there has been some evidence that prescribing physicians as a group have begun to behave more cautiously when it comes to opioids, it is also true that the safeguards that have been put in place have not yet reached their full potential in curbing the problem.

Prescription drug monitoring programs (PDMPs) that are designed to uncover doctor shopping and other patterns of misuse exist in nearly every state and have generated promising results, but many believe the efforts need to be coordinated across states. Says Silver Hills Collins, who maintains an office practice in New York state along with his work in Connecticut, "When I see patients in New York City, I get only their New York state [prescription] data."

The recent move toward rescheduling hydrocodone products to make access somewhat more restrictive is bound to help, Pohl believes, but even that could play out in unintended ways. "The good part about Schedule II is it behooves the prescriber to say that this is a serious drug," he says. However, "One of the bad things is it will make prescriptions harder to get and heroin use will go up," he adds.

Others worry that as health reform expands access to primary care, the time-limited scenario for services will have more patients receiving opioid medications as first-line treatment, and that will work to offset any gains made in stemming the prescription misuse threat. One positive sign, however, involves the better communication among health professionals that appeal's to have emerged in many communities in recent years. In Father Martin's Ashley's location, for example, Bowman sits on a regional hospital task force designed to combat the problem of opioid-seeking behavior.

For those who believe medication-assisted treatment constitutes an important component of the solution, there is always the prospect for new medication options in the future. Collins says he would like to see an even longer-acting formulation of the injectable version of naltrexone (Vivitroi), to improve compliance with what is now a monthly dosing of the medication that is used to treat opioid as well as alcohol dependence.

Asked if the field needs more medication options, Collins replies, "Why not? We don't have something that helps everyone yet."

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Title Annotation:Feature The opioid menace lives on
Author:Enos, Gary A.
Publication:Addiction Professional
Date:Nov 1, 2013
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