Medically-Assisted Therapy: An Outpatient Process for the 21st Century Opioid Addict
Opioid epidemics always have a cause. Many major metropolitan areas experienced problems immediately following conflicts such as WWII and the Vietnam War, when soldiers returned home addicted to heroin. Likewise, the research, attitudes and public policy geared toward the treatment of those addicts were based on the characteristics of the patient population of those times and resulted in systemic responses such as the inner-city methadone clinic model and associated regulations.
The cause of the current spike of opioid abuse is well documented and understood – two decades of increased prescription rates for painkillers has created a nationwide addiction epidemic. Healthcare providers wrote 259 million prescriptions for painkillers in 2012, enough for every American adult to have a bottle of pills. This does not even speak to heroin use and related damages from it.
“I’m a senior executive at a Fortune 1000 company – I didn’t realize I was becoming addicted, it just sort of happened. I was just trying to carry on with my life after a fairly serious medical procedure.”
However, blinded by the image of the stereotypical addict of previous generations, many wouldn’t recognize today’s patient – statistically, today’s opioid addict is a middle-class, suburban woman in her mid-twenties. While opioid addiction can strike all socio-economic levels, all races, and both males and females, the epicenter of the current crisis is decidedly rooted in the middle class and affluent communities across our nation. The concerns of today’s patient are not different than previous generations, however – these are people who others depend on, who are happily married, who have enjoyed a successful career and now their addiction is threatening to take one or all of these things away from them.
There are several choices for the addicts who desire to be free from opiate addiction and all have their merits:
- Maintenance therapy is a key defense against overdose due to the danger of unregulated street heroin, which many addicts will turn to if they cannot find medical-grade drugs. Methadone and buprenorphine-naloxone are the two primary opioids used in this approach. Doctors try to slowly reduce the amount an addict is given over several months, slowly weaning them off of the drug.
- Rapid detox centers use a medical procedure to address physical addiction. The procedures are attractive due to their ability to expedite the detoxification process; however, these tend to be expensive options for most patients as most insurance carriers will not cover the procedure due to its risks and low long-term success rate for achieving abstinence.
- Inpatient and outpatient rehab and counseling centers deal with both the physical and psychological challenges of addiction through a combination of many approaches and have among the best long-term success rates.
A sad fact is that many of today’s addicts perceive too great of a personal reputational risk from seeking treatment of any kind – quick, effective and discrete is the currency of many of today’s addicts who are trying to achieve abstinence. For many, their socio-economic status has contributed to their own prejudices regarding rehab centers and organizations like Narcotics Anonymous. They fear for their privacy due to the interpersonal nature of support group meetings. Furthermore, professionals whose jobs often carry heavy travel requirements can struggle to identify support alternatives when they’re away from their usual groups.
It’s logical to conclude that if the challenges that face today’s opioid addicts differ in many ways from their predecessors and the medical interventions we as clinicians have at our disposal have expanded, then our treatment methods should be designed to take advantage of strengths and mitigate weaknesses. Our facility works collaboratively with our patients to select a counseling or rehab center that is appropriate for their needs and can best amplify the impact of the unique benefits of our treatment process.
Educating the patient
Our facility treats patients from around the country and referrals come from a number of sources – people coming from counselors and courts are somewhat informed, while patients from the web may be taking their first steps toward getting help. As with most things in medicine, our approach to addiction treatment isn’t for everyone and our call operators are trained to help people determine if the medically-assisted therapy we employ is right for them.
“You mean to say that even if my doctor prescribed me some oxycodone that it wouldn’t work?”
For starters, our process for achieving long-term abstinence centers on a patented naltrexone-based therapy that makes further opioid use impossible for practical purposes. Naltrexone is an opioid antagonist – a non-narcotic chemical that blocks the receptors in the brain that opioids (or agonists) must connect with to provoke a response in your body. The treatment can’t literally prevent you from ingesting opioids, but it does prevent any euphoric or painkilling result if you do, which eliminates much of the motivation for the addict. For some people who have other existing medical conditions, a naltrexone-based therapy is not attractive or even unadvisable.
Other factors such as age may make alternative therapies more appropriate for a patient and we try to address all of these during the calls we receive. Not surprisingly, many callers have recently experienced some sort of crisis event that is the catalyst for their pursuit of treatment – they’ve had a close call with the law, their spouse discovered their addiction or gave them an ultimatum, etc. Regardless of their motivation, typically patients elect for our treatment for one or more of three primary reasons:
- Speed – they desire an outpatient procedure to limit the time they need to commit to the detoxification process, allowing them to return to work, family, etc.
- Painless – they fear the pain of withdrawal and are looking for a better alternative to natural detoxification.
- Relapse Prevention – because of the combination of naltrexone formulations and delivery methods we use, relapse is highly unlikely as long as the patient is participating in treatment. The latter consideration often comes into play with drug courts, employers and/or failing relationships where someone is seeking reasonable assurances that the addict will achieve abstinence.
Diagnostics, Consultation and Intake
Patients who elect for treatment are provided with instructions before and after they arrive at our facility. These include typical measurements of vital signs, average daily opioid consumption habits, but also include advice on how to prepare for the procedure and rehabilitation therapies – many patients travel hundreds of miles to undergo our treatment and know little about the laws governing the transport of a schedule II drug for instance.
“I may have done a little cocaine a few night ago…”
One of the challenges of treating addiction is that people are also subject to reputational and legal risks due to their condition, which means they will be tempted to withhold information or lie during a discussion with our staff prior to our procedure. Patients are provided reassurances of their privacy and reminders of the risks of misleading our clinical staff prior to all procedures and it is at this time that we often discover additional substance abuse habits that can be addressed during the detoxification procedure and aftercare.
Patients have limited memory of the detoxification process in our treatment. The hour-long procedure utilizes semi-conscious sedation, similar to that experienced in minor dental procedures, to eliminate the pain and suffering of withdrawal. During this time, we introduce powerful drugs into the patient’s system that work to cleanse the body of opioids – if a patient were completely conscious this would result in immediate and very painful withdrawal symptoms – and begin the naltrexone therapy to aid in the reduction of post-procedural cravings. The procedure is complete when the level of naltrexone present in the patient’s body can prevent withdrawal symptoms for several days.
Importantly, naltrexone-based therapy contributes heavily to the efficacy of aftercare counseling and mental health support. Patients are prescribed the naltrexone regimen for a minimum of one year, which helps them to readjust to an opioid free lifestyle at work and at home. Because the regimen includes periodic doctor’s office visits to administer longer-lasting formulations of naltrexone in addition to oral administration, patients know that someone will be aware if they cease treatment. Likewise, the opioid-blocking effects of the long-lasting naltrexone helps to prevent the possibility of short-term psychological stress creating a relapse incident – this is a weakness of traditional naltrexone-based therapies where patients can cease taking pills for a day in order to achieve a high – because the patient would need to deliberately avoid their naltrexone dosing schedule for weeks at a time. In most cases, the psychological stress that creates the temptation to return to opioid abuse passes before the naltrexone wears off.
Recovery & Rehabilitation
Whether completed through natural processes or through medically-assisted therapy, opioid detoxification is very taxing on the body.
“That first day was a little rough, felt like I had a mild flu. Still, it beats withdrawal.”
Following the detoxification procedure, we monitor patients for 48 hours and tend to their discomfort before discharging them. During this time we further educate the patient on the strengths and weaknesses of our aftercare program and the other community resources that exist that can contribute to their ongoing recovery. Each patient is provided with a plan that involves establishing a relationship with local addiction medicine specialists.
Discharge, Aftercare, Prevention and Relapse Protection
Our customized aftercare program is developed, in part, around a bio-psycho-social interview with each patient. We also employ evidence-based testing that aids and the goals and desires of the patient in the overall planning of aftercare. Following our detoxification procedure, many patients do enter inpatient treatment centers, which are an excellent choice for patients addicted to opiates. We have found that once our patients have gone through outpatient opiate medically assisted treatment, they are free of cravings which allows them to focus on the other areas of their lives that have been impacted by their addiction.
“I wish I would have done this years ago, I was too afraid of the withdrawals.”
On the bright side, today’s addict probably has a better personal support network, is insured and has greater financial and/or other resources that can contribute positively to their recovery. Middle class workers typically own smartphones, are familiar with communication technologies and comfortable using them.
A key to our aftercare program is grounded in the use of telemedicine. Our counseling team provides regularly scheduled weekly online support group meetings using a highly secure communications portal. Our patients rely on the telemedicine offering due to its convenience and the contact allows us to reinforce the work patients are doing with their personal therapist and encourage their ongoing participation in 12-step meetings.
“If you’re on a sales trip with two or three colleagues, you can’t take off for hours to find and attend a meeting if you’re struggling. You need to be prepared for that possibility in advance.”
Telemedicine’s advantages for acute situations cannot be discounted. While patients typically have a dedicated meeting where they form bonds with peers who are experiencing a similar struggle, the fact that they can join our weekly meeting or other third-party online meetings keeps many more patients actively involved in their recovery. However, like many other forms of technology, patients need to be introduced to these options before they will use them and this kind of information is a key element to our aftercare program.
For some patients, the knowledge that we keep track of their naltrexone injections and prescription refills is helpful in their ongoing compliance. The monitoring of the naltrexone therapy combined with online group participation gives us the ability to identify when a patient is at risk and potentially beginning to backslide. In these situations, we can take proactive measures to reach the patient and address what is usually a short-term challenge.
The Road Ahead
We focus on helping patients achieve abstinence for a minimum of one year and we’ve seen great results – better than 4 out of 5 patients remain compliant and active for the entire year following detoxification in an outpatient based program. Addiction is as much a behavioral challenge as it is anything else and 12 months is a key milestone toward long-term recovery. The industry’s average rate of relapse is still relatively high, so it’s not surprising that gaining political support for addiction medicine has been challenging. However, the Affordable Care Act has made treatments like ours accessible to many more addicts via mandates to insurance carriers and that is momentum we must collectively exploit if we wish to make progress against the current epidemic. And that starts with fully understanding our practice and the environment where our patients reside.
About the authors:
Dr. Ricardo Borrego, M.D., a board certified anesthesiologist and director for Eagle Advancement Institute (EAI) and EAI’s addiction specialists and licensed counselors contributed to the development of the ClarityTM Intensive Outpatient Opioid Treatment (IOOT) – the process on which this article is based. Patients, families and referring parties such as medical and insurance providers, schools and courts can find more information at the ClarityTM website or by dialing 1 (888) 431-1502.