Finding Success with a Nontraditional Approach to Opiate Dependence

By Jason M. Jerry, MD

Opiate dependence is a chronic relapsing and remitting illness — few experts will argue this fact. The body of evidence shows that chronic approaches to opiate dependence, such as medication-assisted treatment (MAT) with either methadone or Suboxone® (buprenorphine-naloxone), are superior to acute-care models that involve detoxification and residential treatment.1

Yet the addiction treatment field has long been polarized over whether to pursue abstinence-based approaches or MAT. At Cleveland Clinic’s Alcohol and Drug Recovery Center (ADRC), we believe a fresh approach to this question is long overdue. A “one size fits all” strategy cannot be employed in real-world clinical settings to effect long-lasting change.

Abstinence-based models: The acute approach

Most abstinence-based approaches to opiate dependence presume that patients should enter into residential treatment, where they will be weaned off narcotics during the “detox” phase of treatment and then spend a few more weeks in a rehabilitation program. Such programs typically embrace a 12-step-based approach to addressing the issues underlying the patient’s addiction.

Abstinence-based addiction rehabilitation centers abound in the United States and remain the predominant modality of treatment despite taking an acute-care approach to what is well recognized as a chronic disease. Patients who enter such programs are expected to go away to treatment (usually outside their geographic area) for approximately four weeks and then return home, free of drugs and deemed “in recovery.” If such a patient later has any exacerbation of his or her chronic disease that leads to use of drugs — even on a single occasion — the patient is considered a “treatment failure.”

Traditional MAT programs: Effective but impractical

MAT programs that use methadone as their maintenance medication are required to be federally licensed. Federal restrictions on methadone programs limit their availability, and most moderately sized metropolitan areas have only one or two such programs. Patients in these programs must initially go to the methadone clinic every day to receive their dose of medication, which presents a major inconvenience if they have transportation issues or are trying to reintegrate into the workforce. Many, if not most, of these clinics are located in crime-afflicted areas, and savvy drug dealers often loiter nearby to entice patients to abandon recovery and buy their illicit drugs.

It is no surprise that, despite methadone clinics’ proven efficacy, it is difficult to sell patients on the idea of engaging in long-term treatment at these clinics.

MAT programs that use Suboxone as a maintenance medication are typically run out of outpatient physician offices — often in primary care settings, where Suboxone is provided as a service to opiate-dependent patients by doctors who are not addictionologists. Although Suboxone programs are typically not managed by addiction specialists, it is hard to argue with their effectiveness, which closely parallels that seen with methadone maintenance.

A nontraditional evidence-based approach that works

Cleveland Clinic’s ADRC has been in existence for about 30 years and has a rich history of taking evidence-based approaches to address the complex issues inherent in the treatment of patients suffering from addiction.

Our outcomes with Suboxone have consistently exceeded those reported with traditional office-based programs. For instance, prospective follow-up data from a recent sample of patients (i.e., those started on Suboxone in April 2012) that looked at negative urine drug screens and treatment retention at three and six months of follow-up showed that patients treated at the ADRC had outcomes superior to those reported in the literature by other respected programs2 (Figure).

Figure. The rate of negative urine drug screens among patients in the medication-assisted treatment program in Cleveland Clinic’s Alcohol and Drug Recovery Center (ADRC) compares favorably with some of the best rates reported in the literature.

Secret of success? A combined approach

Our program’s success is driven by a combined approach to treatment: We are neither a traditional residential program nor a typical office-based provider of Suboxone. We provide inpatient services for those in need of detoxification, primarily from alcohol and/or benzodiazepines. Patients who have undergone detoxification or are starting Suboxone typically begin the next phase of treatment in our partial hospitalization program (PHP), where they engage in 12-step-based treatment five days a week. On completion of the PHP, patients transition into one of three intensive outpatient programs.

Close patient monitoring, especially during the critical first 90 days, also contributes to improved outcomes. Patients are required to provide weekly urine samples and are given only one-week prescriptions for Suboxone throughout their first three months in treatment. Patients who struggle in treatment are typically moved to a higher level of care that may involve staying at a local halfway house if they wish to continue in our program.

Our programs are staffed by three board-certified psychiatrists who are certified medical review officers and also board-certified in either addiction medicine or addiction psychiatry. Such heavy staffing in psychiatry allows us to attend to the psychiatric comorbidities that so commonly plague those suffering from addictive disorders.

Evidence tailored to idiosyncrasies

At the ADRC, we pride ourselves on developing treatment plans for our patients that are consistent with the evidence base yet tailored to patients’ idiosyncrasies. The validity of our approach is evidenced by our outcomes measures, the fact that our program has thrived for nearly 30 years and the strong support of alumni who volunteer their time to help those just entering treatment.

Dr. Jerry is a staff psychiatrist in Cleveland Clinic’s Center for Behavioral Health and Alcohol and Drug Recovery Center.

References

1. Jerry JM, Collins GB. Medication-assisted treatment of opiate dependence is gaining favor. Cleve Clin J Med. 2013;80:345-349.

2. Soeffing JM, Martin DL, F ingerhood MI, et al. Buprenorphine maintenance treatment in a primary care setting: outcomes a 1 year. J Subst Abuse Treat. 2009;37:426-430.