Wednesday, September 25, 2013

Is MMT Counseling Replaceable Too?

By now, we've all heard about the recent studies challenging the conventional wisdom on counseling in buprenorphine treatment. Now comes news about a new approach for methadone maintenance treatment, too - this one an even scarier prospect for fellow counselors. Authors of an in-press article in the Journal of Substance Abuse Treatment substituted 1/2 of the traditional counseling in an MMT clinic for a web-based behavioral intervention called the "Therapeutic Education System" (TES). The results showed significantly better outcomes (measured as % weeks of opioid abstinence) in the group randomized to reduced standard treatment plus TES, compared to the group who received only standard treatment.
Figure 2 from the study:
Full-size image (29 K)

As demand for technology-based interventions grows, it's likely we'll continue to see treatment adjuncts like this one more and more often. What I'd like to know is how data like this will be viewed by the chorus of experts advocating for a change to the current MMT-Clinic system? Seems to me it would be welcome news.


Sunday, September 15, 2013

Law Enforcement Views Opioid Overdose Training Favorably

As first responders, law enforcement officers are one of the most common groups of people to witness an opioid overdose. However, no one has ever asked the officers how they would view a training program to equip them to handle this type of situation - until now. A study out of Drug and Alcohol Dependence  indicates that many officers would welcome drug overdose prevention training and, in particular, naloxone/Narcan administration. It seems this study is welcome news to the growing chorus of overdose prevention advocates. As the body of evidence showing these efforts to be effective continues to grow, the importance of involving law enforcement in the discussion is obvious.

The abstract via Science Direct:



Law enforcement is often the first to respond to medical emergencies in the community, including overdose. Due to the nature of their job, officers have also witnessed first-hand the changing demographic of drug users and devastating effects on their community associated with the epidemic of nonmedical prescription opioid use in the United States. Despite this seminal role, little data exist on law enforcement attitudes toward overdose prevention and response.


We conducted key informant interviews as part of a 12-week Rapid Assessment and Response (RAR) process that aimed to better understand and prevent nonmedical prescription opioid use and overdose deaths in locations in Connecticut and Rhode Island experiencing overdose “outbreaks.” Interviews with 13 law enforcement officials across three study sites were analyzed to uncover themes on overdose prevention and naloxone.


Findings indicated support for law enforcement involvement in overdose prevention. Hesitancy around naloxone administration by laypersons was evident. Interview themes highlighted officers’ feelings of futility and frustration with their current overdose response options, the lack of accessible local drug treatment, the cycle of addiction, and the pervasiveness of easily accessible prescription opioid medications in their communities. Overdose prevention and response, which for some officers included law enforcement-administered naloxone, were viewed as components of community policing and good police-community relations.


Emerging trends, such as existing law enforcement medical interventions and Good Samaritan Laws, suggest the need for broader law enforcement engagement around this pressing public health crisis, even in suburban and small town locations, to promote public safety.

Wednesday, September 11, 2013

Relapse Prevention Strategies and Anti-Relapse Medications

A recent commenter asked these questions:

Anonymous has left a new comment on your post "Is Maintenance the Best Therapy for Opioid Addicti...": 

Dr. Willenbring,

Would you agree that a person in recovery should have a solid relapse prevention plan in place regardless of the recovery path they choose. For example a person could choose abstinence-based recovery (AA/NA, CBT, counseling, etc.), Medication Management, or a combination of those, in whatever multitude of variations. Isn't it still imperative that they stay away from their former lifestyle as much as possible?

-Stay away from the places you obtained your drug of choice?
-Stay away from the places you used your drug of choice?
-Stay away from the people that provided your drug of choice?
-Stay away from the people you used with?

What are your thoughts regarding these and other common relapse prevention measures with regard any treatment/recovery option available? 

The simplest answer is that yes, a relapse prevention plan is essential to recovery from any SUD. The examples this reader gives are common-sense strategies designed to reduce exposure to cues that might trigger urges, craving, preoccupation and, most importantly, opportunity. An old saying in AA is, "If you hang around a barber shop long enough, sooner or later you're going to get a haircut." I like the CBT approach of "Recognize, Avoid, Cope." First, do what you can to Recognize higher-risk situations, such as a social event that involves drinking (for someone with alcohol use disorder,) or where you are likely to be stressed or sleep-deprived (you have to work long hours for some reason, or a close family member is seriously ill.) For many people, a trip out of town to a work meeting, or, often worse, their spouse is going to be out of town (when the cat's away...) are high risk. Recognizing allows you to plan your strategy to reduce your risk of a recurrence. 

Second, Avoid the high-risk situation if you can. If a social event is going to involve a lot of drinking or drug use, and it's an optional event, skip it. Why put yourself in that situation? Why stress about it? Besides, one of the first things most people realize is that being sober while the other people are intoxicated isn't any fun. Although they (and you, in the past) may think that they're witty, charming and sexy, the reality is anything but. Typically, intoxicated people are dull and sometimes obnoxious. Unfortunately, avoiding intoxicated people too often means that you have to develop new friends, and you may have to endure some lonely times as that develops. Community support groups such as AA can help by providing you with a built-in social system to bridge that gap, but there are many other opportunities: book clubs, hiking clubs, bicycling organizations, volunteering, spiritual or religious activities, among many others. Be creative!

Finally, if you can't avoid the higher risk situation, develop strategies to Cope with it before you get there. Take a supportive friend, or identify another non-user within the group. Plan an early exit if possible. Practice drink/drug refusal skills. Take an anti-relapse medication (ARM). Remember, no one has any right to know your personal business, including whether you decide to use intoxicants or not. Have one or two stock phrases that 1) don't give a lot of information but don't lie, and 2) don't invite further questions. For example: "Hey, what's up? What's with you not drinking any more? Too stuck up for your bros? Let my buy you a drink, come on!" "No thanks. I just don't like the way I feel when I drink," or "You know, these days it pays to stay sharp, and I get too fuzzy headed if I drink." I'm sure you can come up with others. If the other person persists, you might retort, "Does my not drinking make you uncomfortable? What's the problem?"

One more thing, though, is that I think it's time to give up the false "abstinence-based recovery" vs. "medication-assisted treatment" dichotomy. It's a remnant of 1955. Is someone taking insulin for diabetes on "medication-assisted therapy" versus someone who tries to manage it by lifestyle changes alone? Is someone taking an antipsychotic or mood stabilizer "not abstinent?" My patients struggle at least as much with having to take medications for arthritis, MS, or depression as they do with taking anti-relapse medications. How about ARMs like naltrexone, or disulfiram (Antabuse), or topiramate (Topamax)? If you take those, are you "abstinent?" What if, by trying to "be abstinent," you are a miserable wretch with a high relapse risk, while if you take a medication such as buprenorphine (Suboxone), you are a happy, productive person with a low relapse risk? Why is "being abstinent" automatically thought to be superior, better, and to reflect more positively on you? Is it because we "should" be able to "do it ourselves?" Is it because "God should be enough?" Is it because it shows we are stronger, morally superior, more capable? Why "should" we be "able to recover without medications"? Who says? On what basis? This one idea kills more people with SUDs than almost any other, and I mean that quite literally. Get over it. The brain is flesh and blood. It gets dysregulated just like any other organ and sometimes it is incapable of healing or fixing itself. Sometimes it needs help with medication, as well as social support, psychotherapy, spirituality, exercise, and other non-medication supports and treatments. So what?