Posts Tagged ‘treatment of opioid use disorder’

Year in Review: 2018 and the Treatment of Opioid Use Disorders

This year has been difficult for many people, due to disasters both natural and unnatural. As in any year, good things also happened. Since my blog concentrates on opioid use disorder and its treatment with medication, this entry will focus on the positive events in my field. I’ll save the more negative events for another blog, when I’m feeling grumpy, for those days will surely come.

This last year, the problem of opioid use disorder is got essential attention from governmental agencies, the press, and the public in general. For too long, no one was talking or caring about this issue. Now, this widespread medical problem is getting the kind of attention that leads to change: financial attention.

Big money for treatment

The CURES grant money, approved by legislation in late 2016, made almost a billion dollars available to help treat opioid use disorder. That money was released starting in early 2017, and has helped many patients.

In mid-2018, legislation was passed to approve another near-billion dollars to treat opioid use disorder and its prevention. Called the State Opioid Response, or SOR, this money will be released through SAMHSA to each state’s single-state agency. This money must be used for prevention and treatment, and to increase availability to medication-assisted treatment with the three FDA-approved medications: methadone, buprenorphine, and naltrexone.

From my reading of SAHMSA’s description of the SOR grants (https://www.samhsa.gov/grants/grant-announcements/ti-18-015 ), most of the money will need to be used for treatment with MAT.

This is big money, and is intended for treatment that includes evidence-based treatment with medications. In other words, the abstinence-only, “we don’t believe in medications” type programs probably won’t qualify for these grant dollars.

I’d like to pause and say a big “Thank you!” to the legislators who wisely crafted this grant.

As an example of fiscal irresponsibility of the past, with CURES dollars, some areas of our state cycled patients through five-to-seven- day detox admissions that had very little chance of helping. We’ve known the abysmal data from such short stays for decades, yet many treatment dollars were flushed down that detox drain.

Now, to get grant money to pay for detox, patients will need to start on naltrexone (probably the month-long depot injection) prior to leaving the facility. This makes sense and should improve patient outcomes. They could also be started on methadone or buprenorphine, but presumable inpatient detoxification wouldn’t be needed to start these medications.

The end of a detox is a perfect time to use naltrexone. Once a patient has started on it, it’s much easier to continue, either at an opioid treatment program or even in a primary care office. Since it’s not a controlled substance, physicians and extenders don’t need a DEA number to prescribe this evidence-based medication.

We’ve seen the benefit of CURES grant money at our opioid treatment program, where patients are treated with either methadone or buprenorphine. (We also offer naltrexone, but don’t often get patients when they are suitable for this medication, since they are actively using opioids.)

Before CURES, self-pay patients had difficulty remaining in treatment, and often opted to taper out of treatment before they were ready. Now, we’ve seen those people stay in treatment and thrive. I don’t have data, but I’m sure it is being collected. Now with continued money from the SOR grants, we can continue to provide care to people who have no way to pay for care.

Sometimes people get angry about public funding for MAT. They feel that since they must pay for the treatment of their own chronic disease, patients with opioid use disorder should, too. I can’t comment on the fairness aspect, but I do know that each dollar tax payers spend on MAT saves between $4 – $11 in tax expenses, most of which is saved on incarceration costs, medical costs, and the like.

Personally, I’m happy my tax dollars go towards such a great investment.

Tolerance and inclusivity at some 12-step meetings

I see a trend of tolerance and inclusivity in the recovery communities…at least in my area.

In 2018, a new Narcotics Anonymous group started here with the express purpose of welcoming people on medication-assisted treatment for opioid use disorder. Since I work with patients on medication-assisted treatment, this delighted me. Some of them want to go to 12-step meetings, either Alcoholics Anonymous or Narcotics Anonymous, but don’t feel welcome at the existing groups. Now they have a meeting where they won’t be judged for being on medication, if they chose to share that fact.

This meeting was started by a handful of long-term members of Narcotics Anonymous with more than fifty years of recovery between them. They intended to honor the traditional primary purpose of all 12-step groups: to carry the message of recovery to those people still suffering. The founders of the meeting felt tearing down barriers for people on MAT was the best way to adhere to that primary purpose. At this new meeting, such NA members are full members, with the right to speak at meetings, do service work, sponsor and be sponsored.

The meeting started in February, and attendance ranged from two people to fourteen people per meeting. It’s still in a fragile state, with only a few people coming to nearly every meeting, but it’s a good start.

Some NA members have attended who didn’t share the group’s stated position on the topic. They too were welcomed warmly and asked to return frequently. Attendees don’t have to agree with the group’s position on MAT, as long as they respect the group and its members. Again, emphasis is on inclusivity. Also, the “still suffering addict” isn’t always a newcomer. Sometimes it’s the person with the most time in recovery, so everyone needs to be welcomed.

This is my opinion: if 12-step groups don’t embrace people seeking recovery who are on medications, they will become less relevant. If they fail to reach people on MAT, they will have failed their stated primary purpose, from a lack of open-mindedness and willingness, two of the essential spiritual principles of 12-step meetings.

Breaking Down Silos

I’ve seen and participated in more cross-specialty discussions about MAT in 2018.

In the past, medication-assisted treatment took place at opioid treatment programs (OTPs) and no medical providers outside the OTPs knew what happened there. Some providers and owners of the OTP companies preferred it this way; a low profile might mean no protesters outside, shouting NIMBY (not in my backyard) slogans. They tried to keep everything hush-hush, so the community wouldn’t try to expel them.

Now, providers at OTPs and owners of OTPs are asked to participate in the recovery efforts of people with opioid use disorders. Slowly, as communities desperate for answers have turned to the scientific literature for how best to treat opioid use disorder, they’ve re-discovered the literature that’s been the foundation of MAT at OTPs for decades.

Last year, I was asked to speak to a variety of groups about what we do at opioid treatment programs. In May, I spoke to a conference of U.S. probation and parole officers. In September, I was on a panel of people who spoke at a conference for pharmacists. Also in September, I was invited to talk to our state’s medical board, to explain more about medication-assisted treatment.

All these events were interesting. Some were enjoyable, and one, with the medical board, was transcendent.

I was a little worried about talking to this group, who make up the “doctor police.” When patients complain about a doctor, the medical board investigates. When physicians are suspected of medical incompetence, the medical board investigates. Each physician must have a license issued by the state medical board to work in our profession. By the nature of what they do, medical boards hold a great deal of power.

I was worried about my presentation, mostly because I had about fifteen minutes to explain a few decades’ worth of science, and to dispel the common myths held by most medical professionals about “methadone clinics.”

But it could not have gone better. Board members were welcoming and friendly. I did my presentation, finished just a little over time, and asked for questions. I got great questions that showed they grasped the complexities of treating people with opioid use disorder who have other challenges as well, and how best to treat them without abandoning them.

Another presentation was scheduled right after me, but the meeting halted while nearly all of the board members, who had been seated behind a raised dais, came to me to shake my hand and thank me for coming and tell me how important this work was. I was blown away by their kindness and support, and their eagerness to understand opioid use disorder and appropriate treatment.

I left there glowing. I felt like they understood, like they got what I was saying. The drive from Raleigh to Wilkesboro went by in a happy blur.

More opioid treatment providers

We have more treatment facilities available to treat opioid use disorders Since 2014, around 254 new opioid treatment programs, formerly called methadone clinics, have opened, according to a recent article in the Washington Post. [1]

Prior to that, the number of opioid treatment programs remained unchanged.

We’ve seen a push to get more primary care providers interested in prescribing buprenorphine for their patients with opioid use disorder, rather than referring all of them to specialty programs. Project ECHO at UNC started a few years ago, doing outreach to providers, and support to them in any way needed.

UNC ECHO now has three online interactive sessions per week for buprenorphine prescribers. In those sessions, cases are presented and feedback and suggestions are obtained from other providers. There’s also usually a short teaching session provided by one of the experts, on topics ranging from treatment during pregnancy to payment issues in an office-based practice. Besides providing essential guidance, providers get free continuing medical education credits.

More providers of medication-assisted treatment should mean fewer deaths from overdose. Multiple studies show reduced death risk when patients are on MAT, with an average reduction of death by three-fold.

I’m optimistic about treatment opportunities for people with opioid use disorders. I see a gradual lessening of stigma towards people who have this disorder, as well as towards the life-saving treatments for the disorder. I hope we continue to make progress in 2019.

  1. https://www.washingtonpost.com/national/health-science/some-states-add-more-methadone-clinics-to-fight-opioid-epidemic/2018/11/09/8cace992-e133-11e8-b759-3d88a5ce9e19_story.html?noredirect=on&utm_term=.59a7b585e0aa

 

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