Emphasis shifts in treating addiction
Caregivers dispense drugs, don’t force therapy
By the time Ron Clark walked into Dr. Erin Zerbo’s addiction clinic in Newark, New Jersey, he had already been kicked out of two other treatment programs.
One prescribed methadone, the other buprenorphine. The meds are intended to quiet the compulsive cravings and stave off the withdrawal symptoms that keep people in the grips of opioid addiction. For Clark, they worked. But there were so many mandatory appointments: nurses, therapists, groups. Clark, 60, worked as a laborer, and when jobs came up, he would miss his appointments, and the clinics refused to give him refills, he said. Without his meds, he returned to using heroin.
Traditional opioid treatment programs tie medications to a long list of requirements: support groups, individual counseling, negative drug screens. In clinics such as Zerbo’s – advocates call them “low-threshold” – those resources are available but rarely required. The priority is getting people onto buprenorphine as quickly as possible and keeping them on it.
“We realized early on that in order to keep people engaged in therapy, you had to remove every barrier,” said Lynda Bascelli, a family physician at Project H.O.P.E. in Camden, New Jersey. “Plenty of people still come in weekly to meet with their counselor, because they have a relationship there and they’re benefiting from it.”
Drug therapy, not talk therapy
Methadone and buprenorphine are commonly known as “medication-assisted treatment,” or MAT, where the medication “assists” with the “real” work of treatment, such as talk therapy or 12-step programs. The new approach turns MAT on its head: The medication is the treatment.
More than 40,000 people die from opioid-related overdoses each year. Proponents of the new approach argue that
making lifesaving medications contingent on showing up for counseling increases the risk of overdose.
“You can’t treat someone who’s dead,” said Alex Walley, an addiction specialist at Boston Medical Center.
In Boston, at two city hospitals, people who turn up after an overdose can start buprenorphine in the emergency department or drop in at an addiction “urgent care” center, where even people straight from jail with no ID and no insurance can get started on the spot. In San Francisco, a “street medicine team” distributes buprenorphine to the homeless. In Baltimore, patients can start buprenorphine on a van parked outside the city jail.
Many providers fear the medication only approach “can be a slippery slope if the provider slides into being an ‘enabler,’ ” said George Kolodner, a D.C. area addiction psychiatrist.
The idea of medication-assisted treatment began with methadone in the 1970s. Because too much methadone can cause an overdose, it is regulated
more strictly than almost any other prescription drug. Only federally licensed clinics may dispense it, and patients must go in person to receive their daily dose alongside required counseling.
Buprenorphine, like methadone, eases the craving for opioids, but its chemical properties make it safer than methadone. Treatment with buprenorphine cuts death rates by up to half.
At least 30 state Medicaid programs won’t cover buprenorphine unless the patient is in counseling or plans to attend. Some insurers require proof of negative drug screens and will not pay for a prescription if the patient has used illicit drugs since beginning treatment.
Last year, the Substance Abuse and Mental Health Services Administration encouraged a more flexible approach in treatment protocols: It is “not sound medical practice” to withhold addiction medications any more than doctors should withhold insulin from diabetics who struggle to change their diet or exercise habits, the protocols said.
‘Selling patients short’
The traditional emphasis on counseling and other support services stems from a very real issue: Drug use tends to be one of a long list of problems – mental health issues, infectious diseases, homelessness, a history of trauma.
To offer buprenorphine alone without addressing those other problems is unethical, said Kenneth Stoller, an addiction psychiatrist at Johns Hopkins who requires patients to attend counseling. “Simply providing a low level of care with only medication and then hoping the person will eventually decide to engage further – doing that is selling patients short,” he said.
Those who advocate easy access to buprenorphine choose pragmatism. The most complex patients “are tired of your treatment and have been through the wringer 20 times, and even if they would benefit, would never go back to those intensive programs,” said Joshua Lee, who founded an opioid treatment clinic at Bellevue Hospital Center in New York City.
This is the prevailing view in Zerbo’s clinic, which hosts groups that patients attend monthly, leaving with a prescription. Social worker Joshua Taffet looked over a list of the patients. Alongside their names were the results of their recent drug screens: cocaine, fentanyl, codeine, morphine. Only four of the 14 patients had buprenorphine alone in their system. Half had taken other drugs but not buprenorphine.
Negative buprenorphine tests are a red flag. If the patient has traded or sold medication on the street, he or she has no protection from overdose, and the prescriber could be prosecuted for knowing the person misused the prescribed meds.
Zerbo is such a believer in buprenorphine that she said she’s glad for whoever actually takes the medication. But she wants her patient protected. Rather than taking a punitive approach, she said, she writes a prescription for fewer doses, requiring patients to come back more often to get refills.
“We realized early on that in order to keep people engaged in therapy, you had to remove every barrier.” Lynda Bascelli Project H.O.P.E.