Ask the PCSS-MAT Experts: Addressing Challenging Issues in Addiction Medicine: "Abstinence Based" Treatment Centers

Providers’ Clinical Support System for Medication Assisted Treatment (PCSS-MAT) is a national training and mentoring project funded by the Substance and Mental Health Services Administration (SAMHSA) led by American Academy of Addiction Psychiatry (AAAP) in partnership with: American Osteopathic Academy of Addiction Medicine (AOAAM), American Psychiatric Association (APA) and American Society of Addiction Medicine (ASAM). As part of the project, the below question was recently submitted to the mentoring listserv and is reprinted in ASAM Magazine as part of a new series of clinical support questions and responses meant to help support clinicians practicing addiction medicine. Please note the Mentoring Program and Listserv discussion group and ASAM Magazine are NOT intended to provide clinical consults for specific patient questions and is offered only as a resource for education and overall guidance.

Question: I work as the Medical Director at an "abstinent based" facility. I am Board Certified in Psych and ASAM certified. Our facility is well known for actually treating co-morbid conditions and we do a pretty good job at doing that. We are a 120 bed facility (plus IOP) and are part of a larger network of facilities in various parts of the country. Here's my question. I am struggling to accept the abstinence based treatment philosophy. We offer Vivitrol as maintenance therapy but take a negative view of buprenorphine because of the diversion issue and because of the "substituting one addiction for another" issue. So after patients detox using Subutex the goal is complete abstinence or Vivitrol. I've expressed my feelings about this but get nowhere. I don't know how to break through this position. Any ideas? Thanks--AJ

This question generated over 10 responses on the PCSS-MAT listserve from several different addiction specialists, more than any question within the time period reviewed.

Across the responses, several themes emerged. 

1. The policies described in the question are unfortunately too common and not in line with significant scientific evidence or acceptable medical practice for other psychiatric and medical conditions.
2. Facility policies that withhold or preclude the range of medications for opioid use disorder place patients at unacceptably high risk for relapse and opioid overdose ^[1].
3. The language of “drug-free” and “abstinence-based” treatment or condition is confusing, outdated, and inappropriately applied. Treatment of other psychiatric and medical conditions with medications is commonly accepted practice. The goal of treatment for opioid addiction is not simply abstinence but recovery and sobriety as defined by living a full life without the misuse of medications or drugs (including alcohol). Patients appropriately taking a physician prescribed medication are abstinent from their substance of misuse. 
4. The appropriate role for medications in the treatment of opioid use disorder is as an adjunct to other services to “allow patients to stay engaged in treatment where healing occurs.”
5. More advocacy and work, especially on pre-authorization requirements, is needed to implement the World Health Organization’s list of “essential medications” including buprenorphine and methadone as part of a medication-assisted treatment approach to opioid addiction. 

Responses also generated discussion as to the reasons for the continued existence of restrictive policies on MAT in some treatment facilities. 

1. Owners of “drug-free” or “abstinence-based” facilities often do not have clinical backgrounds so have personal or ideological perspectives on addiction and its care. 
2. Treatment facilities may have financial incentives for restrictive clinical policies as relapse may result in re-admissions and additional revenue. 
3. The historical context of the “drug-free” model does not adequately differentiate between different substance use disorders. It is a useful framework for treating addiction to alcohol where available medications have limited effectiveness, and is virtually the only model for treating and preventing relapse to stimulants and cannabis where no medications exist. It is not a justifiable primary framework for the treatment of opioid addiction anymore. 

Responders noted optimism about the future as more and more treatment facilities review and  change their policies on the range of MAT. Litigation may help drive this change in addition to ongoing focus on the science and advocacy from ASAM members. 

Finally, responders offered ideas for consideration by ASAM and ASAM members on how to respond to the systemic situation described by this question. 

1. Physicians considering work opportunities may want to consider potential liability associated with treating patients in a facility where the full range of MAT is not permitted.  
2. ASAM members should be vocal about the scientific evidence behind MAT and question the preferential referral of patients to programs promoting opioid withdrawal management and “medication-free” approaches to recovery. 
3. Providers can mount public health campaigns in their own communities to inform people seeking help and their families about all the different treatment options and scientific evidence for each. 
4. ASAM and ASAM members should encourage physicians and non-medical health professionals to seek additional training and mentoring on the science of MAT. 
5. Open, honest discussions within the addiction treatment community are needed to examine assumptions about opioid addiction, the historical context of its treatment, and associated ideologies as a way of bridging the divide around MAT.
6. Have addiction advocacy groups come together to create a statement, involve SAMHSA, ONDCP, NIDA, WHO, CDC and publicize it broadly via media channels.
7. Emphasize that access to MAT is an issue across all of medicine, not just addiction medicine or addiction psychiatry. Addiction knows no boundaries and pre-authorization and other insurance barriers to MAT set precedents for other areas of medicine as well.
8. Restrictive policies on MAT also affect physicians who themselves may have opioid use disorder. This should be re-examined as a part of advocacy and future work^[2-8].

As several responders endorsed: “Patients deserve the opportunity to make a well-informed choice about which path they take to [their] recovery.”

• For more information about the Providers’ Clinical Support System for Medication Assisted Treatment (PCSS-MAT) visit  www.pcssmat.org
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  References
  
  1. Cherkins, J. Dying To Be Free: There’s A Treatment For Heroin Addiction That Actually Works.Why Aren’t We Using It? Huffington Post. Jan 28, 2015. http://projects.huffingtonpost.com/dying-to-be-free-heroin-treatment
  2. Earley, P. Letter to the Editor: Opioid Substitution Therapy for Dependent Health Care Practitioners: Approach With Caution. Mayo Clin Proc. 2012;87(8):803-809.
  3. Fiscella, K. Letter to the Editor: Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals Returning to Clinical Practice. Mayo Clin Proc. 2012;87(3):806-808.
  4. Hamza, H, Bryson, E. Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals Returning to Clinical Practice: A Hidden Controversy. Mayo Clin Proc. 2012;87(3):260-267.
  5. McLellan, T, Gregory, S, Campbell, M, DuPont, R. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ 2008;337:a2038.
  6. Newman, R. Letter to the Editor: Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals. Mayo Clin Proc. 2012;87(3):806-808.
  7. Selzer, J, Stancliff, S. Letter to the Editor: Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals Returning to Clinical Practice: A Hidden Controversy. Mayo Clin Proc. 2012;87(8):803-809.
  8. Seppala, M, Oreskovich, M. Opioid-Abusing Health Care Professionals: Options for Treatment and Returning to Work After Treatment. Mayo Clin Proc. 2012;87(3):213-215.
  
  Funding for this initiative was made possible (in part) by Providers’ Clinical Support System for Medication Assisted Treatment (1U79TI024697) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.