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Clinical Leader Challenges Programs That Shun Medication

August 16, 2019

If addiction should be treated comparably to chronic diseases such as diabetes, how can treatment programs justify not offering or even discussing potentially life-saving medication treatments?

Recovery Centers of America's (RCA's) chief clinical officer issued that challenge to a packed breakout session room on Friday at the National Conference on Addiction Disorders (NCAD) East. Deni Carise, PhD, said that no matter what a treatment program's philosophical orientation is, the deadliness of today's drug crisis means no treatment option should be withheld from the patient.

“If we did that in cancer, people would be outraged,” Carise said.

Her co-presenter for the session on the three approved medication treatments for opioid dependence offered a rich historical perspective on how research has informed their use. Charles O'Brien, MD, PhD, founding director of the Center for Addiction Studies at the University of Pennsylvania, opened a methadone clinic in the 1970s and also conducted studies that identified naltrexone as a viable treatment—and later favored its injectable version over the oral formulation of the drug.

The earliest intent for methadone was to keep opioid addicts on the agonist medication for a relatively short time, O'Brien said. But the research kept showing that when methadone doses were reduced in stable patients, they would turn back to heroin.

“When you have someone doing well on insulin, you don't stop the insulin,” O'Brien said.

He pointed out that while naltrexone (usually given as the injectable Vivitrol for opioid addiction) is remarkably safe for most patients, the individual with low levels of functioning and little social support probably is best served initially with the agonist methadone or partial agonist buprenorphine.

O'Brien added, “I would never recommend a medication without counseling.” While Carise agreed that medication and counseling in combination are ideal, she emphasized her view that a patient's failure to attend counseling never should be used to justify withholding medication treatment.

RCA has been expanding its medication treatment options, with a recent focus on introducing methadone treatment into its programming. Carise said she is excited about the treatment chain's involvement in a federally supported study exploring whether these medications can be shown to give the brain time to heal and restore dopamine function. She believes that if this can be demonstrated, it would go a long way toward reducing stigma, by showing that medications such as methadone and buprenorphine do more than simply substitute for the effects of dangerous opioids.

 

Young people and marijuana

Also on Friday at NCAD East, the director of Columbia, Md.-based Congruent Counseling Service discussed strategies for treating addiction to marijuana and other substances in the young “failure to launch” population.

Mark Donovan said he aims for the “uncle” persona—not the harsh disciplinarian—in his clinical work with young people. A believer that everyone essentially wants to grow and have a better life, Donovan suggested that clinicians focus on bringing about small successes on items that matter to youths now (maybe driving privileges, or participating in sports), not longer-term goals that they can't envision at the moment.

“If we figure out where they want to be, then we've got something,” Donovan said.

He offered warnings about drawing broad conclusions from existing research on marijuana. “Most of the research I know of is based on 3 to 5% THC,” Donovan said. “Police are pulling an average 23% THC off the street now.”

At the same time, he concluded by saying that young patients do not necessarily need to stop use to get better. If they can build confidence and see their world as a less dangerous place, they will be able to reduce use as a positive step, he suggested.

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