By Louise Haynes, Medical University of South Carolina
The National Institute on Drug Abuse (NIDA) monograph Principles of Drug Addiction Treatment lists 13 principles of effective treatment, including the use of medication and the value of combining medication with counseling. Yet, for a variety of reasons, many substance use disorder (SUD) treatment programs have been slow to adopt medications in their array of services. In this brief article, I explore some of the opportunities and challenges treatment programs face in adoption of pharmacotherapies and present two examples from the NIDA Clinical Trials Network of community based research that led to the adoption of new interventions that met community needs.
The current, well-publicized rise in the incidence of prescription opioid abuse presents an opportunity for SUD treatment programs to offer a needed service that may previously have been seen as too controversial or too difficult to implement. In 2009, there were approximately 2.3 million people with opioid dependence in the U.S., yet less than 10 percent of those individuals received substitution treatment with methadone or buprenorphine. In the same year (2009), the Substance Abuse and Mental Health Services Administration reported that use of prescription opioids for non-medical reasons was 20 times more common than heroin use. This increase in prescription opioid abuse has resulted in a variety of serious problems affecting communities across the country, and these problems affect individuals, families, and the community at large. One such problem is opioid overdose, which is now the second leading cause of accidental death in the U.S. – second only to motor vehicle accidents (Paulozzi, 2006).
Fifteen years ago, people with opioid dependence were more likely to be addicted to heroin, and their only treatment option was to receive services through methadone treatment programs, commonly known as OTPs. Of all SUD treatment programs in the U.S. today, only about 8 percent are methadone-prescribing programs, a number that has not increased since 2002 (SAMHSA, N-SSATS, 2008). In many communities, the non-medical use of prescription opioids has brought more opioid-dependent individuals into non-methadone treatment settings, but depending upon the services available at the respective agency, the patients may or may not receive the most effective treatment for their addiction. Many of these patients could likely benefit from medications. Unlike the highly restricted use of methadone, appropriately licensed and certified medical personnel may prescribe or dispense buprenorphine or long-acting naltrexone injections (Vivitrol) in a variety of community settings, including both physicians' offices and psychosocial rehab treatment programs.
According to a 2010 SAMHSA survey, there are almost 20,000 physicians who are currently certified to prescribe buprenorphine in the U.S., but the availability of certified physicians varies greatly by region. Many opioid-dependent people do not have access to a physician, and the majority of physicians nationwide are not certified to prescribe buprenorphine. Of the more than 15,000 patients who receive buprenorphine, the majority (73 percent) do not receive the drug through an OTP that provides methadone (SAMHSA), thus demonstrating that when given a choice, most opioid-dependent individuals who seek treatment decide to receive this effective pharmacotherapy in non-methadone, community treatment settings. Psychosocial rehab treatment programs are uniquely positioned to build bridges between medical professionals and counseling professionals who treat addiction. The potential for community based programs to offer SUD treatment services that meet the communities' needs for effective treatment of opioid dependence is clear, and recognizing this need can be an important initial step in reaching a management decision to pursue the integration of pharmacotherapies into their clinical practice.
Yet, regardless of a community's need, multiple barriers, both internal and external, may prevent or delay changes in treatment practices (Kaftarian and Wandersman, 2000). SUD treatment programs typically have limited resources and must choose between competing priorities and mandates from funders. Implementation of new evidence-based practices may not make it to the top of the priority list. One important barrier stems from the lack of sufficient time and effort needed to train staff and address belief systems and negative attitudes toward pharmacotherapy in addiction treatment. Providing the leadership necessary for organizational culture change requires skillful managers who are willing to commit meaningful agency resources toward this goal.
A significant percentage of psychosocial rehab programs do not have medical personnel on staff, and adding pharmacotherapy to the treatment program would require either hiring a medical clinician with specific prescribing authority or establishing a referral network within the community. Another related barrier may result from skepticism about the potential benefits of pharmacotherapy on improving treatment outcomes. To further complicate this dilemma, the past several years have brought funding cutbacks as a result of budget crises at the state and local levels, and consequently, the implementation of new practices has been particularly challenging. Overcoming these barriers requires effective strategies, creativity and motivation, but there are many examples of programs that have successfully met this challenge.
Studies conducted through the NIDA Clinical Trials Network (CTN) have provided opportunities for participating community treatment programs to explore the need and acceptability of a number of interventions, including medications. One such example of the successful implementation of pharmacotherapy in a traditional psychosocial rehab program comes from a CTN study site in a rural area of my home state of South Carolina. Participation in this study introduced agency staff to the use of buprenorphine for opioid dependence and provided the staff training and experience to facilitate adoption. As a result of its successful implementation of the medication procedures and a realization of the local community's need, the agency established a buprenorphine clinic that now provides a previously unavailable service. In July 2013, the local newspaper, The Pickens Sentinel, published an article titled "Study Yields Treatment Plan for Prescription Drug Abuse," which highlighted the clinic's success.
Although not an example of the adoption of pharmacotherapy for addictions treatment, a second CTN project with which I was involved provides an example of how a program discovered and met the needs of its patients through a study of on-site HIV rapid testing in an SUD treatment program where such testing had not previously been offered. As the study got under way, I was concerned about the acceptability of offering on-site HIV testing to our patient population. I asked the opinion of the agency's director of treatment who hypothesized that we would indeed have problems recruiting study participants because the patients might be uncomfortable talking about HIV. Our experience in conducting the study, however, proved that our fears had been unfounded. About 85 percent of the patients who were offered on-site testing accepted the test, even though they had not initially come to the agency in search of HIV testing. Introducing the possibility of testing and providing specific information about the test were the staff's responsibility. We had never envisioned that our patients would consider the offer of on-site testing as a positive addition to the array of services we offered at the agency, but as a result of this discovery, the agency found a way to continue to provide the on-site testing program after the research project had ended. And while this is a great example of how competing priorities can direct an agency's organizational energy and its ability to address a previously unknown need among its patients, it's interesting to note that this same agency has yet to overcome the many challenges inherent to offering medications for the treatment of addiction, with the exception of residential detox.
Evaluating community and patient needs may be particularly difficult when an agency is considering new interventions that are not well known to the community or to potential consumers. Citizens in many communities may be unaware of the effectiveness of pharmacotherapies for addiction. It has been 13 years, prior to the FDA approval and availability of Vivitrol or buprenorphine for the treatment of addiction, since Rick Rawson and colleagues published in 2000 an article titled "Pharmacotherapies for Substance-Abuse Treatment" in Counselor Magazine, a professional journal targeting addictions treatment providers. The article challenged those working in the field of addictions to be forward thinking and not dinosaurs to be rendered extinct by their failure to adapt to advances in addictions treatment. "Learning the nature of the medications, how they work, whom they can help and how they can contribute to recovery will be valuable new areas of study for all addiction professionals."
Today, many years after this warning, we continue to have gaps in the field's progress in meeting this challenge. It is imperative that treatment providers stay current with their knowledge of improvements in effective treatment interventions, educate the community and patients about these innovations, and explore the feasibility of implementation when the innovation can meet a community's or a patient's need. If more community SUD treatment providers offered pharmacotherapies or had cooperative referral arrangements with community physicians, more people with opioid dependence would have an expanded array of choices, and more people would likely choose to seek treatment and find recovery. Our challenge is to successfully and positively integrate medications into our agencies' systems of care to enhance meaningful recovery from addiction.