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:


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.

Source: http://www.journalofsubstanceabusetreatment.com/article/S0740-5472(13)00200-6/abstract

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:

Abstract

Background

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.

Methods

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.

Results

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.

Conclusion

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.

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? 

New Report Sheds Light on Adolescent Substance Use

In a new report by the Center for Behavioral Health Statistics and Quality (CBHSQ), a public health data wing of SAMHSA, we are shown the rates of adolescent substance use through the lens of an "average day". While the overall use of substances declined from 2008 - the previous time this data was compiled -, rates for treatment-seeking have remained stable and the numbers are still quite shocking.

Among the highlights (emphasis mine):  
According to combined 2010 and 2011 NSDUH data, in the past year, nearly 7 million adolescents aged 12 to 17 drank alcohol, nearly 5 million used an illicit drug, and 3 million smoked cigarettes.

In addition, on an average day during the past year, adolescents aged 12 to 17 used the following substances:
• 881,684 smoked cigarettes;
• 646,702 used marijuana;
• 457,672 drank alcohol;
• 38,540 used inhalants;
• 21,775 used hallucinogens;
• 6,747 used cocaine; and
• 5,602 used heroin.

The combined 2010 and 2011 NSDUH data indicate that:
• adolescents who used alcohol in the past month drank an average of 4.3 drinks per day on the days they drank, and
• adolescents who smoked cigarettes in the past month smoked an average of 3.9 cigarettes per day on the days they smoked.
Number of Adolescents Aged 12 to 17 Who Used Cigarettes, Alcohol, or Illicit Drugs for the First Time on an Average Day: 2010 and 2011 NSDUHs:

Source: 2010 and 2011 SAMHSA National Surveys on Drug Use and Health (NSDUHs).

Treatment Data -
TEDS reported that there were 132,850 admissions for adolescents aged 12 to 17 to substance abuse treatment programs in 2010 (TEDS data come primarily from facilities that receive some public funding). TEDS indicates that, on a typical day in 2010, adolescent admissions to treatment reported the following primary substances of abuse:

Source: http://www.samhsa.gov/data/2K13/CBHSQ128/sr128-typical-day-adolescents-2013.htm

The report also notes that in 2011 there were over 280,000 drug-related ED visits by adolescents, and on a typical day, alcohol - alone, or in combination with another drug - is most likely to be involved.

You can see the full report here.

Street-Obtained Buprenorphine: Drug of Abuse, or Proof of Limited Access?

In a recent article from the journal Addictive Behaviors, researchers discovered that buprenorphine was rarely, if ever, used by IV drug users to get high. In fact, the vast majority of people who reported acquiring the medication from an illicit source did so with the expressed purpose of avoiding withdrawal symptoms. This seems to contradict the common misconception that heroin users "get high" on Suboxone, therefore we should promote abstinence-based treatment. To the contrary, studies like this one could be interpreted as evidence there is not enough access to these medications - if there were, people wouldn't be forced to seek the drugs from street dealers or friends.
Interested to hear your take on the subject.

Below is a table from study. You can read the abstract here: http://www.sciencedirect.com/science/article/pii/S0306460313002232

Table 2. Knowledge and Use of Buprenorphine among 602 Injection Drug Users in Baltimore, Maryland.

	Buprenorphine N (%)	Suboxone N (%)	Subutex N (%)	Buprenex N (%)	Any N (%)
Ever heard of drug	537 (89)	355 (59)	52 (9)	68 (11)	541 (90)
Seen sold on street	430 (71)	232 (39)	13 (2)	18 (3)	446 (74)
Ever used	246 (41)	112 (19)	12 (2)	9 (1)	273 (45)
Usual sourcea Doctor Friend Street	124 (50) 32 (13) 55 (22)	71 (63) 8 (7) 18 (16)	9 (75) 1 (8) 1 (8)	6 (67) 2 (22) 0	152 (56) 35 (13) 64 (23)
Used last 3 months	73 (12)	50 (8)	4 (1)	1 (< 1)	95 (16)
Used last 30 days	47 (8)	35 (6)	3 (< 1)	1 (< 1)	69 (11)
year 1stused (median)	2005	2006	2006	2003	2005
Ever used to get high	26 (4)	10 (2)	2 (< 1)	1 (< 1)	30 (5)
Usual sourcea Doctor Friend Street	1 (4) 10 (38) 15 (58)	2 (20) 3 (30) 5 (50)	0 1 (50) 1 (50)	0 0 1 (100)	2 (7) 12 (40) 18 (60)
Used to get high in last 3 months	14 (2)	7 (1)	1 (< 1)	0	15 (2)
Used to get high in last 30 days	5 (1)	3 (< 1)	1 (< 1)	0	8 (1)
Used to get high more than once	20 (3)	8 (1)	1 (< 1)	1 (< 1)	23 (4)

Totals may not add to 100 because of missing, don’t know, and refused responses; Individuals may be represented more than once in the “Any” column if they reported on more than one drug.

a

Proportion of the usual source of drug is among those who had reported ever using/ever using to get high

Citation:

Genberg, B. et al. (2013). Prevalence and correlates of street-obtained buprenorphine use among current and former injectors in Baltimore, Maryland. Addictive Behaviors.

UMN Researchers: Brief Intervention Effective with Adolescent Substance Users

Some promising results out of the University of Minnesota’s Center for Adolescent Substance Abuse Research: brief interventions can help students aged 12-18 dramatically reduce their substance use – in as few as 2 sessions. The team, led by clinical psychologist Ken Winters, PhD, Tamara Fahnhorst, MPH, and Andria Botzet, M Ed., implemented a randomized controlled trial in an urban public school system, delivering one of two treatment conditions, plus a control. The first, student-only condition delivered two one-hour therapy sessions in a two-week period; the second added a session with the parent(s) of the student. The results are impressive: while 37% of the control group reported avoiding cannabis during the last three months at the 6-month follow-up, 63% of the parent-group and over 50% of the student-only group reported the same.

See a complete rundown at Drug and Alcohol Findings or check the Journal of Substance Abuse Treatment for the abstract.

We Still Have a Ways to Go

Very excited to feature a post written by Paula DeSanto, Founder and President of Minnesota Alternatives and a leader in the movement to bring paradigm change to chemical dependency and mental health treatment in Minnesota. Thank you, Paula

We Still Have a Ways to Go

Four years ago I was inspired to open a clinic to help people with substance use issues because of the many, many stories I was hearing about ineffective and often times, harmful treatment.

While we are making progress with embracing more person-centered, stage matched interventions; I continue to have experiences that affirm how far we still have to go.  For example:

I was training a large group of clinicians and practitioners about person-centered care, and we were having a very spirited discussion about why drug and alcohol counselors seem compelled to report their clients use to probation officers.  I have worked as a mental health professional for over 2 decades and mental health clinicians don’t share this compulsion.   In fact, I can’t recall any MH worker ever thinking that this was their professional responsibility.

As this discussion progressed, a man raised his hand and offered a useful perspective.  He commented, “I worked as a probation officer for over 8 years, and throughout that time, we always thought of addiction providers as extensions of us.  There was a strong sense of “we – they” and the counselors job entailed trying to catch the clients using.”

Why do drug and alcohol clinicians think their job includes the role of a correctional officer?

No wonder clients “go underground” in treatment and say whatever they think others want to hear.

Another example:

I was interviewing a young woman who smoked a large quantity of cannabis daily and her parents were very concerned about her well-being.  She had been in treatment previously including some very prominent programs.   I asked this young woman why she smoked pot but before she had a chance to answer her mother jumped and stating, “She smokes because she has a brain disease, and her disease is controlling of her life”.

I again asked the young woman why she smokes, and she proceeded to explain that she smokes to relax especially at night before bed. What unfolded was a discussion about other motives for use and exploration as to whether this young woman even thought she had a problem.

A few days later her mother called me and shared this comment:

“My daughter has been in some of the best programs in the state and I have never heard anyone ever ask her why she uses.  She has always been told that she has a brain disease and they have the fix for it.”

“Kudos to you for asking.”