There have occurred dramatic advances in the treatment of SUD (substance use disorders) in the last decade. Treatment models have evolved from pure abstinence and social context approaches to a new paradigm which incorporates the biological, social, and behavioral components of this heterogeneous disorder into a unifying theme known today as MAT (Medication Assisted Treatment).
The essence of this shift in thinking is based upon the fact that addictive disorders, particularly opioid use disorders, are theorized to be chronic relapsing conditions with compulsive drug seeking behaviors. Research has revealed anatomical differences in the brains of patients with opiate addiction; at the cellular level, neurons are damaged by chronic exposure to opiate drugs. At the macroscopic level, these patients have faulty dopaminergic transmission in the mesolimbic portion of the cerebral cortex, with aberrant reward center processing. Researchers at Mt. Sinai Hospital in New York, are exploring the composition of human DNA, in utero, as a possible prelude to gene editing in the future. There are hypotheses about metaphorical “switches” being opened in patients with “genetic loading”, resulting in opiate cravings even after the original pain subsides, and the need for opiates has dissipated. The implications of these discoveries have a profound effect on the manner in which we view opiate addiction as a society, the manner in which we implement therapy, and how we view persons in specialized environments, such as the criminal justice system. There are almost 2.3 million persons incarcerated in the United States today, and approximately 85% have an addictive disorder in their history.
With these concepts in mind, treatment has become more biologically oriented, and medications have risen to first-line status for not only acute detoxification, but also long-term maintenance. This is commonly referred to as MAT, and such medications are specific for each addictive substance. In opioid treatment, Suboxone, Sebutex, and Sublocade are essential. Long term opioid therapy may also be provided with naltrexone ER (Vivitrol). The utilization of these medications beyond the point of detoxification (heroin, for example), is the newest alternative in opioid therapy. It is not dissimilar from the treatment of diabetes with insulin or Lisinopril for hypertension.
Because these addictive disorders are heterogeneous, clinicians recognize that patients have “psychobiologic illness”, which require treatment strategies that also incorporate behavioral and social context components. Addressing environmental cues in the long term therapy of addiction, is essential, as recognition of “triggers” is the essence of relapse prevention. This holistic approach is not dissimilar from the treatment of schizophrenia or Alzheimer’s disease, and results in a higher level of functioning over a longer period of time. These are chronic relapsing disorders and there is a need to adjust the focus of both healthcare professionals and policymakers,so that treatment strategies are realistic and concordant with the expected outcomes.
There will be relapses, even with the MAT paradigm, but with less frequency and with less severity. The length of time in a state of drug abstinence should be optimized. Less overall substances should be consumed. We are conveying a realistic treatment expectation, as conditions can often be controlled but not cured. The abstinence model resulted in about 80% recidivism (relapses) amongst substance abusers after one year of treatment. This treatment was often spent in detoxification centers, followed by inpatient partial hospitalization (inpatient PHP), then IOP (intensive outpatient treatment). The presumption was that the isolation of the patient in an environment, in which restriction of cell phones, communication with friends and family, and freedom of movement for weeks, would be therapeutic. Many of these patients relapsed during “passes” to the outside environment, and some of them died due to overdoses. They had been successfully detoxified off opiate drugs and “abstinent”. Though their initial motivation for treatment was present, they re-experienced the cravings for opiates, due to their biologic propensity to use drugs. It is “hard wired” in the brains of many addicted individuals, and impossible to control utilizing just “will power” and verbal modalities of therapy.
So, what are the alternatives to the conventional approach currently comprising the majority of addiction treatment?
The first alternative is the prescription of low dose buprenorphine/naloxone (Suboxone) following detoxification, so the vulnerable brain is protected by medication which diminishes cravings and allows the damaged neurons to heal. Suboxone is not just an opiate substitute, it also protects brain cells from the deleterious effects of opiate drugs, without inducing any form of “euphoric high”. Abstinence based treatment maintained for years that Suboxone was no different than street drugs. That misconception differs from scientific studies and clinical practice. These patients experience a far lower recidivism rate after one year; i.e. about 30%. There are also medications which benefit alcohol use disorder and this is incorporated into the MAT paradigm, as well.
The second alternative is environmental. It almost sounds counterintuitive to state that patients will adhere to abstinence and surpass the success of conventional model outcomes in an outpatient program. Patients will complete the program for IOP in three hour sessions, three times a week, for 8 weeks. This format has been utilized with great success in some states, such as New Hampshire. The patients can live at home, continue with uninterrupted employment, and interact with family members. There will be no loss of income, healthcare benefits, or separation issues. Patients can choose a preferred three hour block from a schedule of three sessions each day, attend groups, have MD/ARNP evaluations, and case manager/therapist time. All of the programming of conventional IOP/OP programs will be provided. There will be no restriction of access to their usual environment. The patients begin the program with the motivation to succeed, and will be protected, in part, by the medications which reduce cravings and preserve abstinence.
This outpatient MAT model will save billions of healthcare dollars, and the maintenance of employment will reduce disability expenditures, and loss of productivity in the economic sector. Inmates can be treated for opiate addiction in diversion programs, in which treatment will replace incarceration. The healthcare results and outcomes will far surpass the current conventional forms of treatment at a much lower “price tag” for the patient, the healthcare industry, and the taxpayer.
Many believe this model is the logical next step in substance abuse treatment and that this will be the paradigm for the future.
Charles A. Buscema, MD is the Medical Director and CEO at Alternatives for You, LLC in Palm Beach Gardens, FL which is a MAT (Medication Assisted Program). (561) 337-8880