Which Option Is Best: Abstinence-based or Medication-assisted?
A recent collaboration between a Memphis hospital system and a team of physicians specializing in integrated addiction care has helped increase the number of new treatment options available to patients struggling with addiction in the Mid-South.
However, with the growing number of treatment alternatives also comes a difference of opinion concerning the best methods to care for patients, especially when dealing with opioid addiction. This debate is occurring at both the national and local levels of the medical community,
David M. Stern, MD, CEO of IAC Associates, a physicians group specializing in addiction treatment, says that some physicians and inpatient addiction treatment facilities use an abstinence-based strategy of no maintenance medication during a patient's rehabilitation until after the patient goes through the process of detoxification.
A different approach - one Dr. Stern said is becoming more accepted by the medical community - is medication-assisted treatment, with the patient given medication, in some cases for weeks or months, in combination with counseling and behavioral therapies, to provide a "whole patient" approach.
Lucas Trautman, MD
Lucas Trautman, MD, a psychiatrist and chief medical director at Crestwyn Behavioral Health Hospital, said medication-assisted treatment became more prevalent during the past two decades as medical research revealed that patients, especially ones with an opioid use disorder, could benefit from it as a treatment option during recovery.
"The (abstinence-based) 12-step program has been successful for addictions, such as alcohol, for a long time, but with opioids there is a physical change in the brain which requires medication-assisted treatment," Dr. Trautman said.
"It's hard for patients to get off opioids. There are adaptive changes in the brain, which show craving and dependence, which weren't there previously. We are bridging the gap and saving patients' lives with medication-assisted treatment. It decreases cravings for patients. You cut the death rate in half when a patient uses medications like Suboxone."
Suboxone is a brand name for a narcotic substance that is used to treat patients with opioid addiction. It contains buprenorphine, a partial opioid agonist, and naloxone, which are drugs that target brain receptors which respond to cravings. It's commonly used because it can be administered orally and the patient can take it immediately during the detoxification process. Other medications, like naltrexone, which isn't an opioid, must be injected and require the patient to completely go through the withdrawl process first.
Shawn Hamm, MD
According to Dr. Stern and Shawn Hamm, MD, a fellowship-trained and board-certified physician in both family medicine and addiction medicine with IAC Associates, many patients with opioid use disorder are given buprenorphine at the start of treatment, and some continue to use it during treatment and recovery with counseling and behavioral therapies.
"Our goal is to stabilize the patient," Dr. Hamm said. "We treat the patient with medication first and then introduce other items of care so the patient can remain at home and continue working while incorporating treatment into their everyday lives. Everyone does treatment different. It's a broad bracket, and we want to standardize care."
Dr. Stern, Dr. Hamm and another partner, Drew Blackstock, MD, founded IAC Associates in April. The practice, situated in Bartlett, Tenn., is devoted to what it calls "integrated, wraparound addition care." It incorporates behavioral health, physical health and case management in its treatment model. The practice employs a team of physicians, therapists and social workers to treat patients with addiction. In addition to its current location, IAC Associates plans to open a second clinic in Jackson, Tenn., next month.
This past month, IAC Associates joined with Baptist Memorial Health Care in creating what the practice calls a center of excellence for addiction medicine.
According to Dr. Hamm, many patients struggling with addiction end up in the emergency room because they seek help or medication for overdose.
"Patients may realize they need help but don't know where to go so they go to the ER," Dr. Hamm said. "ER physicians don't know where to send these patients or how to care for them in some cases. Now patients in the ER at Baptist Memorial Hospital, Memphis, can get medication-assisted treatment right away to deal with withdrawal right in the emergency room."
Dr. Hamm says that a physician with the practice can consult with a patient either through telemedicine or face-to-face in the emergency room to determine treatment, including authorizing medication, immediately.
"This is a novel approach in Memphis but is being done in other parts of the country," Dr. Stern said. "We can observe a patient, dispense medication, like buprenorphine, in the ER and set up an appointment with the patient the very next day. It's imperative we stabilize the patient so they can get on with their everyday life. While patients are in recovery, they can perform their jobs and carry on with normal life."
Dr. Hamm said IAC Associates incorporates telemedicine throughout the practice to consult with patients while they are in treatment. He said this can be convenient for patients who live two or three hours away in some cases. Additionally, physicians with the practice can treat any co-occurring conditions at the same time.
"It's so common for patients to have co-occurring conditions with substance use disorder," Dr. Hamm said. "We must get depression, anxiety and bipolar disorder under control. We may have to prescribe antidepressants to dampen the symptoms of anxiety. One physician is prescribing the medication and following their progress."
Dr. Stern said IAC Associates employs the only two fellowship-trained physicians in addiction medicine in the state of Tennessee. He says their approach to addiction isn't taught in medical schools.
"We've modeled this practice to treat addiction as a medical disease," Dr. Stern said. "Physicians aren't typically trained in addiction medicine. Doctors can become a part of the stigma to not treat an addict. There needs to be more education in our medical schools. We are learning more about medication and how it can assist in treatment."
Dr. Stern admits his passion to start IAC Associates stemmed from the loss of his son from a combination of mental health and substance use disorder. He wanted to give patients with addiction a treatment model that's accessible and would have benefited his own son. He said Memphis is an underserved area for addiction, and he thinks the practice's integrated care model will benefit patients with addiction.
"There aren't enough experts in Memphis," Dr. Stern said. "It can be hard for a patient to access care. There aren't enough places for patients to go to receive treatment. Many pain clinics only deal with cash. We take insurance including TennCare."
Radwan Khuri, MD
Radwan Khuri, MD, a psychiatrist and medical director for Lakeside Landing Addiction Services, said he isn't against the concept of what he calls opioid substitution therapy for opioid dependence, but he said it should only be used as a last resort when the patient has tried an abstinence-based treatment program multiple times and the treatment isn't successful. He agrees that there are different approaches in the medical community, and he warns that patients can overuse Suboxone, which can cause additional problems.
"There isn't a quick cure for the disease," Dr. Khuri said. "You don't want to substitute one substance for another. We want to give the brain a chance to heal from addictive substances. It takes weeks or months for the addictive brain to heal."
Dr. Trautman said abstinence-based treatment is a model that has been so successful in the past that patients can have difficulty finding a sober living facility during the recovery process.
"Some sober living houses won't allow patients to live in them if they are on Suboxone," Dr. Trautman said. "This can put the patient at risk for a relapse."
Research evidence on the long-term effectiveness of medication-assisted treatment for opioid addiction is ongoing, but findings from a clinical trial conducted through the National Drug Abuse Treatment Clinical Trials Network in 2016 concluded that patients who were engaged with opioid agonist therapy, like Suboxone, had markedly high odds of positive outcomes.
Dr. Trautman said many non-drug cognitive behavioral therapies are also available to assist patients in their treatment for co-occurring disorders such as anxiety, including yoga, meditation techniques and biofeedback therapy, which is when patients learn to control bodily processes that are normally involuntary such as muscle tension, blood pressure or heart rate.
No matter the treatment method, all addiction experts agree that physicians want the best outcomes for their patients.
"It's important to be empathetic, patient-centered and remove all judgment," said Dr. Trautman.