Psychiatric Annals

Feature Article 

The Optimal Management of Opioid Use Disorder: Leveraging Advances in Addiction Psychopharmacology to Enhance Treatment Outcomes

Michael D. McGee, MD

Abstract

Discharge after inpatient or institutional detoxification for opioids results in postdischarge relapse rates of up to 91%. Addiction psychopharmacology with buprenorphine, methadone, or long-acting injectable naltrexone, augmented with clonidine, can reduce postdischarge relapse rates to as low as 40%. Given the safety and efficacy of these medications when properly prescribed, prescribing clinicians have a duty to inform patients of these treatment options as part of the routine course of treatment and discharge planning. [Psychiatr Ann. 2018;48(5):248–253.]

Abstract

Discharge after inpatient or institutional detoxification for opioids results in postdischarge relapse rates of up to 91%. Addiction psychopharmacology with buprenorphine, methadone, or long-acting injectable naltrexone, augmented with clonidine, can reduce postdischarge relapse rates to as low as 40%. Given the safety and efficacy of these medications when properly prescribed, prescribing clinicians have a duty to inform patients of these treatment options as part of the routine course of treatment and discharge planning. [Psychiatr Ann. 2018;48(5):248–253.]

The literature regarding treatment outcomes for opioid use disorder without addiction psychopharmacology is discouraging. Typically, patients receiving detoxification for opioid use disorder in an inpatient setting or in jail have a risk of relapse postdischarge approaching 91% in some populations.1–3 Approximately 59% to 71% of patients will relapse within 1 to 6 weeks after discharge.1,4 Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) are effective for those who attend these programs regularly.5 Unfortunately, only 8% to 32% of those exiting residential treatment in one study attended NA or AA meetings.6 The practice of abruptly stopping prisoners' methadone maintenance upon incarceration results in reduced treatment engagement after incarceration, a 4-fold increase in subsequent hospital admissions, and a 50% increase in emergency department visits.7 Patients receiving methadone maintenance have the highest treatment retention rates of all addiction treatments.8

Opioid Agonist Therapy

Opioid agonist therapy (OAT), a subset of addiction psychopharmacology, is more effective than abstinence-based behavioral treatments.9 Patients receiving either methadone or buprenorphine have a roughly 50% lower risk of relapse as compared to similar patients receiving counseling or psychotherapy alone.9 Conversely, patients discontinued from buprenorphine maintenance treatment experience a greater than 50% rate of relapse.10

Extended-release injectable naltrexone (XR-NTX) boosted abstinence rates from 31% to 51% across a range of demographics and severity variables in one study.11 In another study, XR-NTX reduced 4-week opioid relapse rates from 88% to 38%.3 Together, the clinical evidence indicates that any patient with moderate to severe opioid use disorder should be assessed for addiction psychopharmacology.3

Abstinence-Based Detoxification

The current standard of care for opioid detoxification treatment at many hospitals and residential programs nationwide is to provide abstinence-based group therapy and detoxification, but to not arrange for OAT or naltrexone treatment after discharge.12 This results in many patients being discharged in the midst of a protracted withdrawal syndrome.13 Protracted withdrawal can last from several weeks to 2 years or longer. Patients suffering from a protracted withdrawal experience intense cravings, emotional lability, anhedonia, impaired concentration, forgetfulness, dysphoria, irritability, anxiety, insomnia, and intermittent low-grade physiological withdrawal symptoms such as chills and sweating. The extreme discomfort of protracted withdrawal, combined with intense cravings, the lack of positive social supports or other recovery supports, the lack of established treatment resources, the lack of recovery skills, and the often-toxic recovery environment to which providers discharge their patients may explain why positive postdetoxification treatment outcomes are so low. Without additional treatment interventions, it can be close to impossible for many recovering patients to withstand their discomfort and cravings and stay sober, especially for those who do not attend mutual help groups.

Further factors that make the postdetoxification recovery from opiate use disorder more problematic include the fact that as many as 53% of patients with opiate use disorder have concurrent psychiatric issues, including trauma, that are not addressed and stabilized during the postdetoxification period.14 Additionally, 49% of these patients smoke.15 Nicotine use reduces positive opioid treatment outcomes and may increase the opioid relapse rate for nicotine users as compared to nonusers.16

In short, many patients leave detoxification with a virtual guarantee of relapse with an illness that has up to an 85% lifetime mortality rate.17 When we compare this to outcomes for other chronic illnesses, such as diabetes, chronic obstructive pulmonary disorder, or congestive heart failure, we realize that these outcomes are unacceptable, especially given that there are new treatment technologies available to dramatically enhance recovery rates after detoxification.

Addiction Psychopharmacology

We are fortunate to be living in an age in which there has been a rapid rise of addiction psychopharmacology. We now have the availability of several medications that markedly enhance treatment outcomes. These include methadone, buprenorphine, and XR-NTX, along with adjunctive medications such as clonidine, prazosin, topiramate, and baclofen.

Many patients prefer to receive addiction psychopharmacology. In one study, 43% of patients surveyed indicated a preference for addiction psychopharmacology, whereas only 12% wished for NA/AA meetings alone and 12% wished for drug-free counseling.2

Patients discharged on a regimen of medications to control cravings, withdrawal symptoms, and protracted withdrawal symptoms have higher recovery rates.18,19 When we compare treatment with and without addiction psychopharmacology, the consequences and conclusions are clear. If we had a loved one suffering from opioid use disorder, we would most certainly want them to have the treatment that would optimize their chances of recovery and minimize their chances of morbidity and mortality. We would also want them to have a treatment that can achieve the highest possible recovery rate. Unfortunately, current standards of care and practice in many hospital and residential treatment centers are not in alignment with evidence-based practice.20

The reasons for this are several, including lack of education, training, and experience in addiction psychiatry, as well as the relative dearth of outpatient providers who provide addiction psychopharmacology. In addition, legislative and regulatory barriers exist that can hamper providing addiction psychopharmacology in an inpatient or residential setting.21

Some ideological controversy exists in the recovery community regarding medications for the treatment of addictions. Many people in recovery, for example, consider those who take methadone or buprenorphine as not being “sober.”22–24 Those in 12-step programs such as AA have endured the suffering of abstinence and in the process became humbled and surrendered to a “Higher Power” as their pathway to recovery. Although this approach to recovery has great value, people must understand that there are multiple pathways to recovery.

Sometimes, the people who are judging the recovery of those on buprenorphine or methadone are themselves using a nicotine patch to overcome their nicotine addiction. The irony is obvious. Or worse, my nonsmoking patients have frequently shared with me being judged as not being “sober,” by NA members who are actively destroying themselves by smoking

The fact is that in many cases medications to treat addictions can mean the difference between life and death, or recovery and despair.25 As wonderful as the 12-step fellowship programs are, they only help a minority of people in recovery. Additionally, for many, the best psychotherapies for addiction are simply not enough.9 People vary in the severity of their compulsions and cravings as well as in their recovery skills and in the availability of recovery supports. It is simply not realistic to cling to an arbitrary ideology that claims that those taking medications are not really in recovery.26 We need to embrace whatever works, including medications, in the treatment of addiction. If medications help patients to reclaim their free will and their lives, if they help to deliver them from the compulsions and cravings of their addictions, if they give them a foundation to work on their recovery and achieve a life of love and integrity, then the good can often far outweigh any risks or costs that come with the taking of medications.

Most clinicians refer to addiction psychopharmacology as medication assisted treatment (MAT). MAT is an unhelpful term at best and one that the authors feels should be abandoned, as it implies that medications are secondary, or an adjunct, to core addictions treatment. This is like saying insulin is MAT for diabetes, rather than simply saying insulin is a treatment for diabetes along with nutritional interventions. Just as it would be strange to refer to insulin, antibiotics, anticholesterol medication, or antihypertensive medications as MAT, it is unhelpful to refer to addiction psychopharmacology as MAT. Words are important. They have meanings and connotations that carry sometimes hidden assumptions and understandings. In this case, the term MAT carries the message that addiction psychopharmacology is not as central to the treatment of addictions as other nonmedication interventions.

It is true, however, that addiction psychopharmacology is a double-edged sword. If not used skillfully by both the prescriber and the patient, it can cause more harm than good.27 In my experience, one of the risks of medications, especially when they are extremely effective, is that they can make people feel that they are cured and that they don't have their addiction anymore. Medications can invite complacency. Some people then stop taking their medications and promptly relapse, sometimes with fatal consequences.

By delivering patients from the torture of their addiction, medications can take away the lifesaving “gift of desperation” that motivates them to engage in daily recovery practices and rituals, such as going to meetings, seeing a therapist, attending group therapy, working the 12 steps, or engaging in daily prayer and meditation. Medications should empower patients to develop their recovery skills and supports, not alleviate them of the need to work on their recovery. Recovery activities, just like regular exercise and a good diet, should be part of a daily lifestyle whether patients take medications or not. A good prescriber will insist that their patients participate in a recovery program that both appeals to them and is effective. Medications are not a substitute for recovery work. Good treatment for addiction encourages patients to work on the three pillars of recovery—abstinence, well-being, and citizenship—while simultaneously taking medications.

As with all medications, the medications for the treatment of addiction have risks and side effects. Both the prescriber and the patient must balance the benefits against the risks and costs.

The power of addiction psychopharmacology calls for a change in our standard of care for the treatment of opiate use disorder. As with all treatments and medicines, we have a clinical, ethical, and legal duty to inform our patients of all treatment options that might help them. We also need to discuss the risks, benefits, and side effects (if applicable) of these different treatment options, and then to work to provide the treatment that is the most effective, most efficient, and most acceptable to the patient.28 For the treatment of opioid use disorder, there is clearly a mandate to offer patients ongoing addiction psychopharmacology if at all possible.

Rarely in medicine do we have situations that are so clearly black-and-white and so compelling. Many intensive residential treatment settings and other intensive treatment settings forbid the use of addiction psychopharmacology for ideological reasons inconsistent with empirical reality.29 There is a need for a cultural shift in this regard. We need to let go of ideology and embrace evidence-based treatment to provide optimal treatment for opioid use disorder.

OAT Medications

First, as with all other illnesses, patients should receive education on available treatment options. Patients should be offered methadone, buprenorphine, or naltrexone as part of their discharge plan. These medications can then be bolstered with additional medications such as clonidine30 and other medications that can ameliorate postacute withdrawal symptoms. In my view, this should be the standard of care for all patients.

Buprenorphine providers exist both within and outside of intensive treatment settings. Several buprenorphine provider directories exist, and providers can find treatment slots with patience and persistence (Table 1).

Directories of Buprenorphine Providers

Table 1:

Directories of Buprenorphine Providers

Methadone maintenance clinics exist, especially in urban settings, with relatively easy access and availability for patients for whom methadone maintenance treatment is indicated.31 Appropriate patients for methadone maintenance typically have more severe biological dependence severity and lower psychosocial functioning. They often must live in toxic recovery environments, lack healthy recovery supports, lack a healthy social network, and suffer from concurrent psychiatric issues, including trauma, that impair their overall functioning and ability to pursue recovery. If a patient presents with an intractable opioid use disorder with multiple relapses and failures of other treatment options, consider methadone maintenance.

XR-NTX and oral naltrexone are options for patients who are motivated for recovery to the point that it is almost a life mandate because of the severe adverse consequences that may result from relapse. Patients suffering from opiate use disorder treated with naltrexone should receive adjunctive palliative medications for postacute withdrawal symptoms32 as well as good substance abuse therapy to optimize their chances of recovery. It is also essential to set up external contingent reinforcement systems with care providers and significant others to maximize adherence. Finally, patients on naltrexone should engage in other recovery activities to build a support network and develop their recovery skills. Recovery activity options include 12-step programs, SMART (Self-Management and Recovery Training) recovery, Refuge Recovery, and other mutual-help recovery meetings.

For patients starting methadone maintenance, initiate methadone maintenance up to 72 hours prior to discharge if allowed. This allows for the discharge of patients with greater stability as they then transition to a methadone maintenance treatment program.

Recent research has shown clonidine to be an effective agent for dealing with stress-related emotional instability and stress-induced cravings.30 Addition of clonidine can further enhance a positive treatment outcome by reducing stress-induced recurrences of addiction.

Encouraging patients to detoxify from nicotine during their inpatient detoxification also enhances recovery outcomes,13 likely due to reduced cravings and relapse rates. We need to debunk the myth that it is best to address one addiction at a time, as this myth does not coincide with the reality of recovery in the author's view.

Intensive treatment programs need to look at changing their internal policies and procedures for patients who wish to receive addiction psychopharmacology after discharge. Administrators should encourage physicians to become certified to prescribe buprenorphine if they are treating patients with opioid use disorder. Physicians need to obtain a waiver from the Substance Abuse and Mental Health Services Administration to prescribe buprenorphine, and an additional Drug Enforcement Agency registration number (see http://www.dpt.samhsa.gov/ for details).

Treatment programs may want to consider short-term solutions to enhance outcomes. One would be to consider a comanagement model, in which certified addiction prescribers participate in the treatment of patients needing this treatment. Another option would be to transition the care of patients needing addiction psychopharmacology to a prescriber competent to provide this treatment.

Figure 1 presents an algorithm for the management of opioid use disorder. It emphasizes the importance of educating patients about their treatment options so they can make an informed decision, along with their clinician, as to what is best for them.

Opioid use disorder inpatient management algorithm.

Figure 1.

Opioid use disorder inpatient management algorithm.

Conclusion

We need to evolve our standard of care for the management of opioid use disorder. Providers should offer addiction psychopharmacology routinely to all patients with opioid use disorder. Although challenging, discharge planners/case managers need to aggressively search for and obtain addiction psychopharmacology treatment providers for patients find it beneficial. Providers should develop a bio-psycho-social-spiritual formulation and treatment plan during the initial days of treatment so that if it appears that a need exists for addiction psychopharmacology postdischarge, the planning can begin as close to the time of admission as possible.

Some might argue33 that it may be close to malpractice to not offer a patient highly effective treatment options for a highly lethal disease. There may be a medical-legal argument that enhances the urgency of this issue, in addition to the clinical, ethical, and humanistic dimensions of this problem.

This article offers an evidence-based rationale for the addition of addiction psychopharmacology to other interventions for the treatment of opioid use disorder. It is the author's hope that traditional substance abuse treatment programs that do not offer addiction psychopharmacology will consider it to provide ethically sound and effective treatment.

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Directories of Buprenorphine Providers

Provider Website
SAMHSA <ext-link xmlns:xlink="http://www.w3.org/1999/xlink" xlink:type="simple" xlink:href="https://www.samhsa.gov/medication-assisted-treatment/physician-program-data/treatment-physician-locator" ext-link-type="uri">https://www.samhsa.gov/medication-assisted-treatment/physician-program-data/treatment-physician-locator</ext-link>
Suboxone <ext-link xmlns:xlink="http://www.w3.org/1999/xlink" xlink:type="simple" xlink:href="http://www.suboxone.com/treatment-plan/find-a-doctor" ext-link-type="uri">http://www.suboxone.com/treatment-plan/find-a-doctor</ext-link>
Treatment Match <ext-link xmlns:xlink="http://www.w3.org/1999/xlink" xlink:type="simple" xlink:href="https://www.treatmentmatch.org/index.cfm" ext-link-type="uri">https://www.treatmentmatch.org/index.cfm</ext-link><ext-link xmlns:xlink="http://www.w3.org/1999/xlink" xlink:type="simple" xlink:href="https://www.naabt.org/zipcode.cfm?page=patient_dr_connection.cfm" ext-link-type="uri">https://www.naabt.org/zipcode.cfm?page=patient_dr_connection.cfm</ext-link>
Authors

Michael D. McGee, MD, is the Chief Medical Officer, The Haven at Pismo.

Address correspondence to Michael D. McGee, MD, WellMind, PO Box 545, Avila Beach, CA 93424-0545; email: mdm@wellmind.com.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/00485713-20180417-01

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