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Saturday, March 7, 2015

Arguing For Suboxone Clinics

"Long-term, low-intensity outpatient treatment that fully integrates mental health treatment, pharmacotherapy… achieves superior outcomes with greater patient satisfaction at a fraction of the cost."

--Mark Willenbring

Arguments abound about the worth of treatment centers that distribute Suboxone and other substances to help curb opiate abuse. The recurring criticism is that "these patients are merely trading one addiction for another." I believe understanding the value of this ongoing treatment is essential for those who really care.

Read the opening quote from Dr. Mark Willenbring again, slowly. Concentrate on several well-chosen words that rankle those looking for quick fixes and immediately effective treatments. Consider these words again:

long-term =  "great or much greater than average duration"
low intensity = "low key as opposed to extreme force"
fully integrates = "engaged in all phases by bringing all parts together"
superior outcomes = "higher quality, not flawless" outcomes
greater patient satisfaction = "higher opinion of care received"
fraction of the cost = "a small part" of the cost

Considering the content of the sentence, Willenbring makes a substantial claim for supporting new and better treatment.

Mark Willenbring, M.D. and founder of Alltyr -- a corporate structure for clinical, educational, advocacy and research efforts -- is the former Director of the Division of Treatment and Recovery Research of the National Institute on Alcohol Abuse and Alcoholism at the National Institutes of Health (NIH) in Bethesda, MD.

Willenbring has spent over 30 years as a clinician, scientist, teacher and leader. Prior to NIH he was Director of the Addictive Disorders Section at the VA Medical Center in Minneapolis and professor of psychiatry at the University of Minnesota. His research and leadership focused on new treatments for patients with chronic complex problems and implementing evidence based practices in clinical settings.

Willenbring wants to spur a change in treatment. He is convinced that the current addiction rehab system doesn't work well, doesn't make sense, and is too expensive. He thinks the problem, even with those touting 12-step treatment programs, is that they have gotten themselves, and everybody else, convinced that this approach is 100 percent effective.

Of course, no treatment for addiction is 100% effective, but according to Willenbring, in these 12-step programs, there is no accountability for poor outcomes. They blame the patient, who feels like a failure, and it encourages the family to condemn the patient for not recovering.

There is a myth, Willenbring says, "that you go into a rehab program, the light shines through, angels sing, there is a wonderful revelation, and you never take a drink again. That's a rare outcome." For example, he said it takes 5 to 10 years for people with chronic alcohol dependence to quit drinking after periods of recurrence and abstinence.

(Mary Ann Grossman. "Most important path to recovery from addiction? For one expert, it's simple: flexibility." mgrossman. St. Paul Pioneer Press. May 26, 2013)

The Time For Recovery Is a Wide Variable

As frustrating as this seems for the medical field, the patients, and the loved ones of those addicted,  the truth is that no magic, one-fits-all formula for recovery and healing exists. Instead, deliverance involves a complicated rebirth that mends hearts, souls, and lives. This often takes long, long periods of time.

Placing all understanding of addiction into a narrow view of abuse as simply self-inflicted destructive behavior, critics believe addicts, no one else, are solely responsible for their fate. They see great time and money going to waste as relapses so often occur. Then, after seeing rehab failures, many tend to condemn recovery altogether, which essentially sentences those still addicted to futures that involve long sentences behind bars or certain death. This judgment is neither ethical not biblical in its foundation.

Perhaps it is time to re-evaluate the best use of allocations. Mark Willenbring states ...

"For opioid addiction (to such drugs as heroin and pain killers), long-term maintenance (not 'detox') on the medications buprenorphine/naloxone (e.g., Suboxone, Zubsolv and others) or methadone are the only treatments with solid empirical support, and opioid maintenance therapy is among the most powerful and cost-effective treatments in health care.

"There is no high quality evidence supporting the use of either residential or outpatient rehab for treating opioid addiction. Not only are these maintenance medications seldom prescribed, many rehab programs discourage them! They routinely recommend 'abstinence-based' treatment (i.e., without the medications just mentioned.) If an oncologist failed to prescribe a life-saving chemotherapy for cancer because she 'didn’t believe in it,' she would not stay in practice long. Why do we tolerate this practice in treatment for addiction?"

(Mark Willenbring. "Can Addiction Rehab Ever Be Evidence-Based?" Addiction Treatment Methods, Living with Addiction. December 21, 2014)

A Different Model of Care for Substance Use Disorders

Willenbring started Alltyr Clinic in 2012, and structured it to operate as a clinic, not a program, and to offer outpatient services tailored to the individual patient. Length of treatment was also individualized.

A majority of his patients have had prior exposure to rehab whether residential, outpatient or both. As one patient put it, “It was easy when I was in rehab, but when I got home, life happened!” The important work is struggling to recover when “life is happening.”

Willenbring says most people have to make multiple quit attempts -- that is, they suffer recurrences. His staff works with patients to minimize the frequency, length and severity of recurrences, and then to learn from them to help prevent the next one. They attempt to change patients' approach if the current one is not working.

Most of his patients are eventually able to achieve sustained recovery, but it often takes one to two years or more of continuous or intermittent treatment. And there really is no “end date”  -- they can come back for help, be it one year, five years, or whenever and for whatever length of time they require. (They don’t have to start all over again or make a time commitment.)

Willenbring believes the most important strategy to reduce illicit opioid use: rapid and affordable access to effective treatment. He concludes ...

"For established addiction to heroin, OxyContin and other opioids, the only effective treatment is an indefinite prescription of either Suboxone or methadone. The scientific findings are clear on this. It may not be the answer people want to hear, but maintenance therapy like this works, and abstinence-based treatment does not.

"Of course there are exceptions to the rule, but the relapse rate after abstinence-based treatment is greater than 90 percent. And people are dying because of it."

(Mark Willenbring. "Letter of the Day Feb. 17: Heroin addiction."
Minneapolis Star Tribune. February 16, 2013)

We know this is NOT the answer we prefer to hear, but it seems to be a model of care that works. We must ask ourselves if we are willing to change our stand and metaphorically "swallow the bitter pill" as it stands before us by admitting traditional rehab experience has, at best, some success, without relapse. It is not a panacea, not even close. Other promising methods must not be discouraged.

Relapse is most often a symptom of ineffective treatment programs. And, many inpatient rehab centers provide only a temporary fix that can sometimes evaporate when their patients go back into the real world.

Here are the results of a 3-month follow up of 242 opioid-dependent patients in residential treatment in the National Treatment Outcome Research Study: 34% of the patients relapsed to heroin use within 3 days, 45% within 7 days, 50% within 14 days, and 60% within 90 days.

(M. Gossop, D. Stewart, N. Browne, J. Marsden. "Factors associated with abstinence, lapse or relapse to heroin use after residential treatment: protective effect of coping responses." Addiction 2002; 97:1259-1267)

Recognizing that opiate addiction is a disease that often requires long treatment regimens is a step in the right direction. The patient that can function and find a decent life in the real world should be encouraged to continue effective medication. Tom McClellan, CEO and co-founder of the Treatment Research Institute in Philadelphia, says inpatient rehab came out of a belief that to get better, you just had to be a better person. McClellan explains ...

"We used to understand addiction 40 years ago as a bad habit, low character development [and] poor impulse control.
"So what was envisioned was a program that first tore the patient down, stripped the patient of his bad habits, and then reconstructed a person who was more socially responsible, more honest and had better character."

Today, McClellan says addiction needs to be treated like diabetes. He says it would be unthinkable for someone to go to their priest to find a cure for diabetes.

(Staff. "For Addicts, There May Be Another Road To Wellness."
National Public Radio. June 08, 2014) 
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