Editor’s note: This commentary is by Dr. Rick Barnett, who has worked as a licensed alcohol and drug counselor in numerous settings for over 20 years and is the current president and CEO of CARTER Inc. (the Center for Addiction Recognition, Treatment, Education and Recovery), a private nonprofit organization in Stowe. He is past president and current legislative chair and lobbyist for the Vermont Psychological Association. He serves on several other groups and committees including the Green Mountain Care Board Health Care Provider Advisory Committee and on the Unified Pain Management Advisory Council at the Department of Health.
In his January 2014 State of the State address devoted exclusively to the topic of drug addiction in Vermont, Gov. Peter Shumlin suggested that we are not going to prescribe our way out of the opioid epidemic. Specifically he said we cannot “just use maintenance drugs as a Band-Aid for this complicated disease” and we cannot “just dole out maintenance drugs that sometimes find their way back into the drug market.” And yet, this is exactly what we’ve done and committed ourselves to doing. Einstein said, “You cannot solve a problem with the same mind that created it in the first place.” We’ve prescribed our way into our addiction to painkillers by the relentless plugging of “Pain as the 5th Vital Sign” campaign which trained hordes of health care workers to engage in liberal prescribing practices and increased patient demand. Now we are trying to prescribe our way out of the problem by over-prescribing maintenance medications for addiction. We’ve embraced hook, line, and sinker the alleged evidence-based, maintenance medication craze that has swept our country – with what kind of results?
Here’s the data: Fatal opioid overdoses have increased from 4.5 per 100,000 people in 2003 to 7.8 per 100,000 people in 2013. A recent report from the Centers for Disease Control states that since 2000, there has been “a 200% increase in the rate of overdose deaths involving opioids (opioid pain relievers and heroin). From 2013 to 2014 alone, rates of opioid overdose deaths increased 14 percent. Medication-Assisted Treatment (MAT) is touted as the No. 1 solution to the heroin and prescription opioid epidemic. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), MAT includes comprehensive maintenance treatment, detoxification and medically supervised withdrawal. Maintenance drugs have been pushed since the approval of office-based treatment, while detoxification and medically supervised withdrawal is rarely offered and even vociferously discouraged. Maintenance drugs include buprenorphine (“Bupe” or Suboxone) and methadone. An opioid-blocker called naltrexone (also known as Revia and Vivitrol) is also used but doesn’t help with cravings and isn’t considered a maintenance drug.
The dollars pumped into the system to pay for these medications has increased year after year while funding for psychosocial and mental health treatments has dramatically decreased over the past 20 years. Vermont Medicaid has cut group psychotherapy rates by over 80 percent since July 2015 and now claims that psychotherapy needs better monitoring to see if it’s actually helpful.
Let us transform our state from leading the pack in our high rates of addiction into leading the nation in developing the best community support systems and the highest quality treatment programs and professionals.
The system is rigged: It sets people up to fail. Patients demand the drugs and we prescribe. Access to non-drug treatments is blocked while maintenance medication is being promoted like never before. Everyone is taught that MAT is the best practice and Suboxone is held out as the golden ticket to freedom from opioid addiction. Then, we are told allegedly by the research that up to 90 percent of people weaned off these life-saving medication will relapse.
This is baloney for two reasons. First, the system isn’t geared to helping people come off maintenance meds. Hence the term “maintenance” — one is “maintained” on the medication to stave off cravings and relapse. Second, the main outcome measure for a majority of this research is retention in treatment, that is, whether or not someone stays on the medication. In other words, if a patient stops taking their maintenance meds or simply drops out of the program, it’s considered a treatment failure, i.e. relapse.
This couldn’t be more misleading and here’s why – Vietnam. Didn’t our experience with the last wave of heroin addiction among soldiers returning from Vietnam teach us anything? The Lee Robins Study showed two things: 1. Nearly 1 in 5 Vietnam soldiers got addicted to heroin or opium, and 2. Of those, nearly 90 percent kicked the habit without treatment. The study was even ahead of its time by demonstrating that early intervention with less severe dependence (casual or novice users of heroin) has an incredible rate of success – without medications! This is perhaps best illustrated in the 2015 TED talk with nearly five million views by Johann Hari called “Everything You Think You Know About Addiction is Wrong”.
The federal law responsible for the MAT Drug Abuse Treatment Act of 2000 or DATA 2000 doesn’t even require counseling. In fact, some providers believe that counseling may actually be a barrier to treatment. Yet prescribers need only complete an eight-hour online course to become certified to prescribe Suboxone. Many of those who complete the brief training don’t even write a single script or soon realize the complex challenges associated with treating addiction. The solution is not to prescribe more medications or get more providers to prescribe. The solution is better education and training and building a more robust treatment system with a massive emphasis on psychosocial rehabilitation, and community supports which may or may not include maintenance medications.
Suboxone is the perfect, or at least most available, medication to stave off withdrawal until you can get more heroin or your drug of choice. It’s been called a heroin helper by a member of Congress. It’s a popular street drug that produces euphoria contrary to how it’s promoted. For many, it’s the first and only opioid they ever use. Providers and patients alike crave access to complementary and effective non-drug treatments like counseling, formal treatment programs, or peer-recovery groups. Maintenance drugs are supposed to be used as tools in a vast toolbox of treatment options.
At a March 29, 2016, Prescription Drug Abuse and Heroin Addiction Summit in Atlanta, President Barack Obama highlighted three new actions by the federal government to escalate the fight against the opioid epidemic: Increase the number of patients one prescriber can prescribe to from 100 to 200, support more widespread distribution of naloxone, an overdose-reversal drug, and enhance mental health and addiction treatment parity. All of these initiatives are excellent. Those prescribers who have gained the most experience with treating addiction should be allowed to reach more patients but not without a robust community and professional support systems to back them up.
Let’s rename Medication-Assisted Treatment (MAT). Let’s call it Counseling-Assisted Medication-Optional Treatment (CAMO-T) and use funding and our common sense to emphasize counseling and community support to create the kind of change required to overcome addiction. Promoting the idea that taking a pill is the first step on the path to recovery is simply dangerous.
Einstein is also credited with the famous phrase: “Insanity is doing the same thing over and over again expecting different results.” Right now Vermont Medicaid is committed to doing the same thing over, by limiting access to non-drug treatments: keeping group counseling reimbursements rates at record lows and potentially limiting the number of individual counseling sessions. Instead, we desperately need Vermont to dare to be different. Let us transform our state from leading the pack in our high rates of addiction into leading the nation in developing the best community support systems and the highest quality treatment programs and professionals.
