Medication Assisted Treatment for Opioid Addiction

Just got done reading an interesting piece on the headline topic on NPR website:

Apparently the makers of Vivitrol are lobbying hard to get states to use their product at the expense of other products. This is just a heads-up on the subject. These issues are, of course, controversial, but for the first thing to know is when laws are being made, who benefits and who doesn’t? I find it troubling, however, that a maker of a drug being promoted to treat addiction is trying to get ahead by stigmatizing addiction and stigmatizing competing methods of treating addiction that have been shown by research to be effective.

Thoughts on medication assisted treatment for substance use disorders– I have worked in substance abuse treatment and mental health for about thirty years now. I remember back when there were two possibilities– antabuse (disulfiram) for alcohol, and methadone for opiates. Taking disulfiram was sort of like blackmailing yourself. “If I drink, I’m going to make myself really sick.” The thing was, some people didn’t even get sick if they drank on it, and other people could get sick if a vinaigrette salad dressing had any alcohol content. So at it’s best, it was not a great tool. But thing about was that every day you either took it, or you didn’t. If you took it, that meant you were planning on staying sober. If you didn’t take it, that meant you were planning on drinking. So it was a daily gut check.

Methadone, on the other hand, was still pretty highly stigmatized– and still slammed (as the article above points out, still today) as trading one addiction for another. And you still had to structure your day around it, getting to the clinic in a relatively small window and dosing, and in some cases, dealing with the fact that the dose wasn’t properly adjusted & you might end up too sedated to even use public transit, much less drive safely, or you might start to get dope sick later in the day. And you had to be a little angel for a long time to get take home doses. And don’t even try to get methadone for high levels of chronic pain.

I’m not closely in touch with the part of treatment that’s doing methadone these days, but I’ll bet it’s still a big hassle. I do know some people who have done office-based suboxone treatment and have had great success. And, just like people on antidepressant medication, some people have a long term goal of being off it, others don’t. Personally, I don’t see the fuss, but I’ve been in the treatment world for a long time. Isn’t it about having your life work?

Now let’s talk for a second about my clinical experience with people doing Vivitrol. What the article didn’t mention is that there are doctors doing it for people with alcohol use disorders.  There’s a certain amount of literature about people using it to deal with alcohol cravings. My clinical experience is that this application is pretty hit-or-miss. There are people who’ve done it with a goal of becoming casual or controlled alcohol users.  I haven’t seen that work out. Also, if you look at the substance use treatment literature, no reputable providers think that medication-only strategies really do the job. There has to be some kind of psychosocial component (read: counseling). Granted, that’s what I do, so I’m biased. Without a psychosocial component, though, it’s not uncommon for people do drug switching to something that naltrexone doesn’t affect, like cocaine or methamphetamine.

Now let’s take a sec to talk about the abstinence-only people. Unfortunately, there are a lot of them, including what I have sometimes called the Christian Science wing of AA. They don’t want people taking psych meds, they don’t want people doing medication assisted treatment, they want you to refuse opiates for a broken leg, and maybe will grudgingly allow you anesthesia for open heart surgery. Fortunately, the genius of the Twelve Traditions & the Twelve Concepts (the latter extremely little known) which structure the larger movement, it’s essentially impossible for one group to hijack the movement and impose a monolithic party line.

Fortunately, times are changing. I remember taking an adolescent client with a substance use disorder to an AA meeting where one of the members got up and gave a rambling, disjointed monologue. The person next to me leaned over and whispered, “He’s bipolar but doesn’t want to take the medication.” However, it was said with a tolerant smile, and the person was a regular. Another time, at the same meeting, a member apologized for coming late because they were at a psychiatry appointment getting a medication adjustment.  That person, too, was fully accepted by the group.

My greater concern is that across the nation there are many places which bill themselves as substance abuse treatment, some of them very expensive,  which do little more than take people to 12-step meetings and do structured step-working groups.  Some of them are contractors to local governments. (Just as an aside, the 9th U.S Circuit Court of Appeals ruled some years ago that people convicted of DUI can’t be forced to go to AA meetings by the courts because a Higher Power looks too much like God) As a taxpayer, I don’t like the idea of my tax dollars going to pay for people working 12 steps when they can do that for free.

Don’t get me wrong– I support 12 step groups. There is a body of research that shows people who connect with AA (the 400 pound gorilla of 12 step groups; others are much smaller) are more likely to have better treatment outcomes.  I just don’t feel comfortable with it as a treatment modality that people have to pay money for. the AA literature itself emphasizes that it should be voluntary and that AA should be independent of other institutions to work.

This post is becoming rather rambling, and I don’t have a clear destination. But I guess the main thing that moved me to write after having seen the article quoted at the top is that after all these years, it’s still so hard to get treatment, and that stigma is not only hanging on, but being used as a tool to make money by a manufacturer of what is represented as a treatment tool. The tool itself is not that great, in my clinical experience, but if they want greater sales, they should encourage more treatment of all kinds for all kinds of substance use disorders, not disparage other providers of other tools. After all, the disease has overtaken car crashes as a cause of death. If you’re really trying to help, don’t be so greedy.


About jamesmatter

Marriage and Family Therapist (MFT) in private practice in San Francisco. I work with adults, adolescents, and couples, with focus on substance use and abuse and co-occurring disorders (having both a mental illness and an addiction).
This entry was posted in Addiction, choices, Recovery, stigma of addiction, Uncategorized and tagged , . Bookmark the permalink.

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