The CDC released a report recently showing that life expectancy in the US had fallen due to the opioid crisis. After decades of steady increase in life expectancy due to advances in medicine, surgery, prevention and immunizations we are sliding back due to the scale of the opioid pandemic. I was sad, but not shocked. I was not at all surprised at the scale of the problem and know it’s projected to increase. However, I was most saddened at the climbing death rate knowing the way we treat opioid addiction is inadequate and effective solutions are underutilized. We have the means and knowledge based on evidence based practices to treat opioid addiction more effectively with better outcomes but there is no unified national approach to coordinate a higher standard of care. If any other public health problem were big enough to lower life expectancy, you can be sure there would be a sweeping “All Hands On Deck” approach with cooperation among researchers, care providers, medication manufacturers and stakeholders. We saw this with the AIDS epidemic. Yet without the same concern for those suffering with addiction the death rate climbs so high that our societal life expectancy starts to plummet. It doesn’t have to and it’s urgent we change our approach to treating opioid immediately.
I have spent the last two decades responding to the addiction crisis in one way or another. In 2003, I led the team that got FDA approval for buprenorphine and helped lobby for the law that allowed primary care physicians to prescribe it for up to 100 patients. I later oversaw the largest network of opiate treatment clinics in the country and now have taken what I’ve learned to create a comprehensive model of care that deploys the best practices with the best results to save lives. I have learned that a few factors in how a person receives treatment have an enormous impact on whether they will successfully enter recovery or succumb to their addiction to opioids. These simple changes in treatment delivery are profoundly cost effective and easy to implement without re-inventing any clinical models. Here are some of the basic principles:
1. No person should be receiving medication from a doctor without a companion behavioral health and counseling regimen. Medication Assisted Treatment (MAT) is exactly what its name states – a pharmaceutical assistance to treatment. When we worked to get buprenorphine approved in 2003, the rationale that allowing primary care physicians to provide the therapy in their office was that it would get the most help to the most people fastest. There was also a presumption that a partnership between conventional medicine’s primary care physicians and the addiction treatment behavioral health world would develop to insure the counseling and individual and group support we knew was necessary accompanied all those prescriptions. This seemed like it would be a natural evolution born out of a desire for patients to succeed. Unfortunately, some of the elements that would compel this partnership never came to fruition and we now have thousands of patients whose sole experience with Medication Assisted Treatment is filling a prescription from their primary doctor, with no additional care components to help their success. Patients then are prone to abuse the medication (buprenorphine is subject to abuse AND has a street value), sell it on the street, or combine it with benzodiazepines like Xanax. These patients rarely succeed and often overdose and die. This is born out by published reports that show that while buprenorphine is the 15th most prescribed medication in the country, it is the 4th most diverted. Many experts estimate that 50% of prescribed buprenorphine is diverted or sold illicitly.
2. The second critical principle is that a 28-day residential model is the least desirable option for opioid treatment for most patients. Success rates for a short term residential model are poor with 71% of patients relapsing at some point in the year and 47% still using addictive substances after 12 months. Opioid addiction is treated in most residential models in the same manner as other substances despite the availability of medications to assist these patients existing for decades. The reality is opioid patients have had a dramatic abuse of the mu receptors in their brains and studies have shown outcomes are dramatically different when medications such as buprenorphine are employed in their treatment. As a result, we see opioid addicts are the first to leave residential treatment AMA. Additionally, as shown in multiple peer reviewed journals, studies reveal that a short term detox of opioid patients as done in residential treatment facilities increases morbidity and mortality by 92%. The best outcomes seem to happen when there is long term engagement through an outpatient program over a period of time. This not only cares for the patient through a medically supervised initiation of therapy in the very beginning, as well as those fragile early weeks, but extends into the patient’s need to create a new routine and make lifestyle changes that avoid relapse triggers and nurtures a life in recovery. Working with a counselor during this entire treatment program provides the framework for a patient to understand their behavior and to rebuild their life going forward. With an average of nine months in outpatient treatment, only 13% of patients experienced a relapse and only 11% were using addictive substances after a year. Long term intensive outpatient programs are extremely cost effective and cost the insurer and or the paying patient and their family drastically less than residential programs. A traditional treatment program can cost anywhere between $80-350,000 with a 13% success rate whereas a comprehensive intensive outpatient program costs about $36,000 (nine months at $4,000) The outpatient program also takes places where a patient lives, works or goes to school – this is more beneficial than the destination rehabs that patients travel to only to return home and be shocked back into their environment with all its triggers during the delicate relapse prone weeks of early recovery. Long term remission of cravings and successful recovery depend on a patient being able to function and manage their own lives in the place where they are and creating and nurturing a support network of friends, family, allied health professionals, counselors, doctors and successful recovering peers through a 12 step community, house of worship or other structure. Displacement and disengagement in the traditional residential models are deadly elements in the transition from addiction to early recovery, and the obscene costs are a barrier to access to care for most people.
3. We must keep an addiction-trained physician at the center of the care team, and training is key. In 2003 we thought that increasing the number of doctors able to prescribe buprenorphine by including family medicine doctors, general practitioners and internists meant more patients would receive treatment. At the end of every training program, we would encourage all attendees to get certified in addiction medicine. The mantra was that 8 hours of training doesn’t teach you how to treat an addicted patient- it taught you how to medicate them. Data shows that if a physician has no addiction training then the biopsychosocial needs of the patient receiving the prescription are often neglected. Many don’t feel that it is their responsibility to follow up on this requirement. The office setting is inadequate and unsettling for patients and no coordination occurs with other health professionals such as counselors and addiction therapists. Medication Assisted Therapy is most effective when it’s part of a larger comprehensive treatment plan and the prescribing physician has enough addiction training to assess where the medication fits in the overall addiction treatment plan for the patient. Dr. Sally Satel, an American Enterprise Fellow and Yale lecturer, made the point in her op ed piece in the Wall Street Journal earlier this year. No doctor would prescribe diabetes medication in a vacuum without comparing reports from a cardiologist and internist, and no doctor should be treating a chronic lifelong disease like addiction without knowing the context and influencing factors. It’s almost impossible that addiction thrives without the co-morbidity of anxiety, depression or other mental health symptoms that also require treatment. You need to know where to look and what to look for to have a prayer of succeeding in treating opioid addiction, and therefore physician training and specialty certification is a must. Right now, only an 8-hour course is required to be licensed to prescribe buprenorphine, which is dreadfully inadequate to successfully treat this disease and all its complex challenges.
4. The optimal model for treating opioid addiction is an Opioid Treatment Program (OTP) utilizing buprenorphine and other approved medications. An OTP is a facility that is regulated by a number of both state and federal agencies, including SAMHSA and the DEA. These facilities provide both behavioral health services (individual counseling and group) matched with medical care. The medications are dispensed on site rather than prescribed. Additionally, the facility is federally mandated to do random drug call backs to ensure that patients are not abusing or diverting their medications.
Why is this model not seen today?
1. Most OTPs are methadone clinics treating underserved populations funded by Medicaid. These clinics are modestly funded at best and these rates do not make buprenorphine possible for these patients.
2. As a result of the higher cost of buprenorphine, historically the for-profit clinics are hesitant to embrace this option due to the fear that existing methadone patients will want to switch to buprenorphine and thus hurt profit margins.
3. Some states have not allowed the new federal regulations that allow OTPs to use buprenorphine as an office based physician would and thus require patients to come daily to receive their medications. This makes it virtually impossible to have patients receive buprenorphine within the structure of the OTP and the behavioral health services.
4. For the few OTPs that are focused on patients with commercial insurance, insurance companies want to pay a facility like a doctor’s office which makes the provider choose between giving away care for free or providing limited care as disjointed providers. There is still hesitancy to contract in a value based manner as insurance companies are looking to increase access to care but only the disjointed model- individual contracts with physicians or counselors. This is good for PR but not necessarily for their members. Worse yet, data shows that this type of care costs the insurance company more- but the costs are scattered across multiple providers, emergency departments and hospitals.
These changes to the opioid treatment model are not unknown nor are they my unique epiphany. I have proven they work and have the patient outcomes to prove it. But if its less expensive and more effective, why isn’t there wider adoption? That answer involves a long and complicated exploration into our cultural views on drug addicts and the myths that still surround addiction as well as the institutional failures that have contributed to the crisis. Perhaps the life expectancy falling will be a wakeup call, and the answers are right here!