Clinicians who are unfamiliar with addiction medicine are sometimes skeptical about the value of opioid treatment programs, or lack the information to objectively identify a quality program for patients who need treatment.
Forum Editor Jean Fisher Brinkley asked experienced addiction medicine specialist Dr. Jana Burson, who practices in North Wilkesboro, to offer some guidance.
Q: What are the most common misconceptions other clinicians have about medication-assisted treatment (MAT) for opioid use disorder?
A: Many clinicians don’t realize that medication-assisted treatment using either methadone or buprenorphine for opioid use disorders is one of the most heavily evidence-based treatments in all of medicine. Using these two FDA-approved opioid agonists has been shown to reduce mortality more than three-fold.
MAT studies also show it improves the lives of patients with opioid use disorder, with better physical and mental health measures, improved employment status, and drastically reduced incarceration rates. Patients on MAT also have reduced risks of both HIV and Hepatitis C transmission.
Clinicians also often assume that a short treatment episode is better than maintenance, which is contrary to outcome studies. It appears patients who stay on MAT the longest do the best. Some patients may be able to live their best lives if they stay on MAT, while others may be able to taper off the medication after adequate counseling and after lifestyle changes are made.
Like any other medical treatment, MAT isn’t right for every patient. Some patients are too sick for outpatient treatment with MAT and others aren’t sick enough. For example, if a patient isn’t using daily and has no physical withdrawal with opioid cessation, MAT may not be appropriate.
Q: What should a referring clinician look for in an opioid treatment program (OTP)?
A: Good opioid treatment programs have these characteristics: they use adequate dosing; that is, they increase the patient’s methadone dose high enough to stabilize the patient and block euphoria from abused illicit opioids. They hire staff with training and experience and provide frequent trainings for their personnel. Good OTPs have medical directors with a significant physical presence at the facility, who serve in a leadership role, rather than “rubber stamping” decisions made by non-medical staff. Good OTPs have good communication with medical staff, counseling staff, and administrative staff.
Many rural communities are an hour or more away from an OTP, and office-based buprenorphine providers may be the only choice for medication-assisted treatment.
For office-based buprenorphine treatment providers, similar characteristic should be sought. The prescriber should lead a treatment team that may include on site counseling services, both group and individual, peer support services, twelve-step facilitation or any combination of these services.
Q: How can a clinician determine if MAT is working for the patient?
A: Objective tests like drug screening help determine how patients are doing in treatment, but a broader view of the patient’s overall functioning gives a more complete assessment. There should be an improvement and stabilization of the patient’s overall life, with improvement in financial stability, physical health, and all of the social determinants of health.
Even if the patient isn’t drug-free, termination of MAT treatment should not be undertaken lightly. Patients forced to leave MAT have a three-fold increase in their risk of overdose death, so even if the patient is struggling, best evidence suggests we see better outcomes when that patient is retained in some sort of treatment.
Most MAT providers embrace a harm reduction strategy and try to retain patients in treatment even with continued positive drug screens. However, if the patient is using sedative drugs like benzodiazepines or alcohol, staying on MAT may actually increase the risk of death. It’s a difficult decision, best made by a provider who knows the patient well.
The patient’s other healthcare providers can be of enormous benefit when they contact the opioid treatment program (OTP) to coordinate care.
About Dr. Burson: Jana Burson, MD, has specialized in the treatment of opioid use disorder since 2004. She is currently medical director at an opioid treatment program in North Wilkesboro and maintains a private practice where she treats patients with opioid use disorder with buprenorphine products. Dr. Burson is also a mentor with UNC Project ECHO, which provides MAT education, mentoring and practice support to new MAT prescribers in all 100 NC counties (See UNC ECHO article for more information). Dr. Burson blogs about the treatment of opioid use disorder at janaburson.wordpress.com.
