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NCAD Spotlight: Fentanyl Driving Abstinence-Based Treatment Programs to Consider MAT

October 18, 2019

Having observed the impact fentanyl has had on communities in the eastern half of the United States, Andrew Stone, MD, MPH, a consulting physician specializing in addiction medicine, internal medicine and pulmonary at Eleanor Slater Hospital/RI BHDDH, says previously abstinence-only treatment programs are starting to embrace the implementation of medication-assisted treatment.

Stone will present on abstinence-based programs adding medication-assisted treatment and the need for communities to destigmatize the use of medication in recovery at the upcoming National Conference on Addiction Disorders West in Denver. Ahead of his session, Stone spoke with Behavioral Healthcare Executive about abstinence-based programs shifting strategies, the need to reduce shame around MAT, and why fentanyl is creating a greater sense of urgency for treatment programs to evolve.

[Editor’s note: This interview has been edited for length and clarity.]

What have you seen lately with regards to formerly abstinence-only treatment programs implementing MAT? Why do you think these programs have shifted their thinking?

I think a lot of people have had a change of heart about adding medication to 12 Steps-based programs because there has been a recognition among many programs that there is too high of a death rate for people who are in abstinence-based programs who then subsequently relapse because they’ve either lost their tolerance for opioids or they are not on a blocker medication, such as naltrexone. The death rate has been too high to go it alone, so a lot of programs have branched out to include both, which has the benefit of encouraging people for longitudinal and long-lasting recovery but also keeps them safe should they relapse during the earliest, most vulnerable time in their recovery. That’s why it has been a natural extension for programs that were previously “abstinence-only” to include medications, and I think that has been a good thing for all of our patients, especially in the fentanyl-endemic areas, where risk of relapse once tolerance is lost comes with a higher risk of death.

It seems like the data bears out that this shift is making a difference and improving outcomes.

Absolutely, both in individual programs—I quote Hazelden, which has added Core 12 and studied that extensively over the past few years, on the inpatient side, they’ve added medications such as buprenorphine to their treatment program. Their retention rates have gone up, and they’ve done some longitudinal studies that show patients who do continue on the medicine continue to do well once they leave. To contrast that with an urban outpatient program in Baltimore that looks at both the effect efficacy of medications and effect efficacy of patients who engage in 12-Step recovery, and showing the combination of those on medication who also choose to go and do 12 Steps work, they have better outcomes than medication alone or no medication at all. There’s data that shows that not only is this feasible and doable, but it's actually improving outcomes for our patients with addictions involving opioids.

Can you discuss the importance of shame reduction with regards to medication-assisted treatment?

I think part of the reason there has been some struggle with formerly abstinence-based programs putting medications on board is that there is some stigma applied to patients by outside influences that suggest medication is copping out or not true recovery. That can shame our patients, and they internalize that and say ‘I’m a bad person because I need medications to maintain my recovery.’ Reducing our own unconscious biases and sometimes conscious stigmatizing language reduces shame in folks struggling with addiction so that they can get the best outcomes with the least amount of resistance from themselves or the culture at large. It’s important to reduce overdose death rates through all modes of treatment.

I’m a passionate advocate for shame reduction and destigmatizing in general, because I think it can save people’s lives. People ought not to be shamed for taking medications if they need it, and they should not be stigmatized by our society or other folks in recovery if they’re unable attain recovery without the assistance of medications.

In prior conversations we’ve had, you have shared that you have observed fentanyl starting to migrate from east to west. How does that fit into the bigger picture here regarding the implementation of medication in previously abstinence-only programs?

Fentanyl is the impetus for me stressing the need to reduce shame and stigma around the need for medication and to try to include medication in formerly abstinence-based treatment programs simply because the overdose death rates have skyrocketed in places where fentanyl has become endemic. As fentanyl creeps across the country in fits and starts, programs that previously were successful in abstinence-based treatment where a relapse on heroin or a prescription opioid didn’t mean a fatality, they’re not as likely to die as somebody who relapses and the only substance they can relapse to in the area is fentanyl because fentanyl has replaced heroin or illicit pharmaceutical-grade opioids in the area. That’s why it’s important to destigmatize medication and decrease shame in asking for help with medication and to consider adding medications where it once might have been reasonable and safe to say let’s try without medications first in areas where fentanyl was not a large part of the illicit drug supply.

I think it’s inevitable that like the East Coast and the Midwest, the West and Mountain West likely will see the same problems emerge with fentanyl contaminating the local drug supply so that when people end up having a relapse, they’re at a much greater risk of dying. That’s why I tie all of these things together that we need to have all hands on deck to recognize the dangers of fentanyl when it comes into a community, how a 12-Step program can facilitate medications for folks who need to prevent overdose deaths should somebody relapse, and make sure people and communities decrease the amounts of stigma attached to people who may have the disease of addiction so that the shame for those individuals is not so great that they are reluctant to start on those medications if those medications are advisable.

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