According to Kenny House, vice president of clinical services at Coastal Horizons, the science on medically assisted therapies (MAT) is clear.
“The studies show that people who are on those medications for longer than two years, do better in terms of outcomes than those who are not on medications. In saying that, I want to be really clear: There are people that find recovery without medications, but we have to understand that that is a much lower percentage of the population that suffers from this disorder,” said House.
House added these medications can be increasingly necessary, especially if the abuse has gone on for longer than a year. The brain, according to House, really requires a process of normalization and stabilization, and medications like methadone and buprenorphine can provide that.
Dr. Amanda Culp-Roche of the University of North Carolina Wilmington’s School of Nursing agrees with House — these medications help those with opioid use disorder (OUD) return to a normal life,
“Whereas if they're not on MAT, we know that they can tend to spiral downwards; we see children who are taken away from parents with OUD and placed with either grandparents or even into foster care; we see that they cannot maintain or functionality in their jobs,” said Culp-Roche.
Culp-Roche said it’s about ‘harm reduction’ and decreasing overdose death rates with these medications, “Especially when we're talking about buprenorphine, naloxone, it's a safer medication. The overdose on those medications is very, very low.”
She added this keeps those with OUD away from the streets where they are more easily exposed to intravenous use and could contract HIV or Hepatitis C.
Culp-Roche said dosing depends on where the person is on their road to recovery, essentially that it’s individualized. But when starting the medication, it’s all about timing, said Culp-Roche, ”we hope they are in withdrawal when they come to our clinic, typically 12 hours after their last use is kind of that sweet spot, and sometimes a little longer.”
Culp-Roche said people can stop Suboxone use successfully. She gave an example of a client who had entirely tapered off the Suboxone, and after a couple of months wanted a monthly injection of naloxone or Vivitrol — opioid blockers — as a safety net, as to not to return to use. She noted that one potential issue with Vivitrol is that patients have to be completely through withdrawal and into a period of abstinence. At that point, if a patient uses an opioid, Culp-Roche said the medication would trigger immediate withdrawal in the person, something that patients desperately want to avoid.
Questions about medically-assisted treatment
Mike Townsend is the recovery administrator for the Kentucky Housing Corporation. He works with 18 recovery centers across the state, which include The Healing Place facilities.
“If you look at only overdose deaths, then Suboxone and methadone are very efficacious in terms of decreasing deaths. Do they increase recovery? Long-term Recovery? That's a question that I don't know that I believe has been fully answered yet. And yeah, you could say with the methadone and the Suboxone, ‘Well, they are an answer also.’ And yeah, I agree with it," Townsend said.
Culp-Roche said MAT can also be lifelong therapies, but “then there are other people that we can taper down, off. And in my practice, I have seen that where I've had some success.”
Asked if most on OUD need to be on these medications Culp-Roche said, “I don't think there is a clear answer to that; it really is dependent upon the person, dependent upon their environment, dependent upon their background and any kind of trauma that they have been through.”
Potential for abuse or diversion
But critics say those who use medications like Suboxone are not treating the underlying opioid misuse —and that the medication can be diverted to the streets.
Dr. TK Logan of the University of Kentucky, who has followed the success of recovery programs in the state, which include The Healing Place, said, “when we talk to people, they'll get the prescription, they'll sell half of it, use half of it, in order to basically just maintain their own dependence, but also try to make money off of it by diverting it to other people on the street. That's kind of a typical scenario that we have seen a lot in Kentucky.”
And while Kenny House of Coastal Horizons reports that telehealth was an important tool in getting people help during the pandemic, Marla Highbaugh, the director of development and communications for The Healing Place, said people were taking advantage of this system to get drugs like Suboxone.
“At least in our area, which probably was happening across the United States was doctors were no longer required because of the pandemic to actually see their clients, they were just giving them the medications. So they did not know if people weren't going to counseling anymore; they were just sending those types of drug prescriptions on,” said Highbaugh
Culp-Roche said, yes, Suboxone can be diverted, that’s why they have accountability measures like, “the random urine drug screens, we do the random pill counts. We use the state’s monitoring report system to make sure they’re getting the medication — they’re not getting it too soon or they’re using different pharmacies to try and fill too early.”
She also said Suboxone is also typically used with another drug, naloxone, that cancels out the euphoric effects of opioids, “so and with that naloxone combination, it makes a little bit harder to misuse buprenorphine,” said Culp-Roche.
But Townsend said, “Many of our men and women, at least in Kentucky, many have not had good experiences with opiate replacement medication. Some have said, ‘Yes, it's been helpful to me for a period of time.’ Individuals that we've encountered have indicated that the medication for opiate replacement basically just held them all over until they could get other drugs that they really needed. And they really weren't serious about recovery when they were using the methadone or Suboxone.”
Furthermore, Townsend said, they sometimes have explain to the public why they don’t use MAT at their facilities: “And so some people say to us, ‘Well, why aren't you giving these people of Suboxone while they're in the program?', and we go, ‘Well, we're trying to treat the entire recovery situation.’”
And he said some of the residents in recovery in Kentucky have learned to outsmart the system: “I'm allergic to that medication, I want something that is not the blocker, then you can just basically use the Suboxone and get a euphoric high from it if you take enough of it. So a lot of our residents say, ‘Well, we've played all kinds of games with doctors to try to continue our drug addiction.’”
Taking OUD seriously
UNCW’s Dr. Culp-Roche, who is teaching future nurses to dispense Suboxone, said OUD is a serious condition, “It's a disease. We even have a medical diagnosis for it. It is truly a problem. It's not a societal thing. It's not a decision that people can make.”
Kenny House of Coastal Horizons said these medications need to be available without shame, “Just as we would with antidepressants for someone who suffers from clinical depression, just as we would for insulin for someone who suffers from diabetes, these are medications that treat the brain and normalize functioning, and they should be thought of and supported in that kind of way.”
Culp-Roche added, “It is truly an organic neurobiological disease, and we know that it's a remitting, relapsing disease. So there's going to be days where those patients are kicking OUD’s butt, and then there's going be days where OUD is kicking their butt.”
She said the medication is there so people have more days where they win more than they lose.
But Dr. Logan, an alcohol and drug abuse researcher, said medications like Suboxone don’t address the root causes of the OUD dependency: “And that's what these programs that Recovery Kentucky, and even the outpatient programs, that's what they do, they focus on those coping skills, which I think are really important to do. Medication-assisted therapies do not spend as much time on that if any.”
Culp-Roche disagreed, saying, “So it's not just the clinician writing the medication and sending the patient out the door. There is a huge amount of work that goes into helping a patient stay sober and stay on the road to recovery.” That means connecting patients to psychiatrists, peer support groups, or other mental health professionals and/or counselors.
New Hanover County's The Healing Place
The debate over medically-assisted treatment has played out in the development of the county's drug and alcohol treatment facility, The Healing Place. Coastal Horizons was initially slated to be the operator, and would have provided MAT. But the Trillium, which handles state and federal funding for mental health, later decided to go with The Healing Place of Kentucky — which will not offer MAT — and county commissioners agreed.
Logan said future patients of The Healing Place are from vulnerable populations — and will be using more than one substance, not just opioids.
“So they are targeted for homeless or at risk of homeless and or involved in the criminal justice system, at least in Kentucky. So it's very difficult for this group of individuals to complete traditional substance use or to adhere to MAT or whatever,” said Logan.
Additionally, Townsend said for The Healing Place facilities in Kentucky, most of their populations are polysubstance users, “Anything that will alter consciousness is kind of the approach that we've seen, and that represents probably 90% to 95% of our residents. We have very few people that are strictly only alcoholic or only heroin users.”
Culp-Roche said yes, Suboxone only works well with opioid misuse; however, if the person is abusing several different drugs, and opioids are the main choice, the medication can still work.
But Logan is skeptical that even this population can follow a regimented schedule for medications, “So again, medication adherence, in general, is difficult. We're not good at it. We don't take our antibiotics even all the way right. But if you're homeless, if you're stressed out, if you don't have that stability, it's really hard to do that.”
And while supporters of The Healing Place model say they feel this is the best holistic approach to dealing with substance misuse, Kenny House of Coastal Horizons said, “let me say that we will be fully supportive of The Healing Place for the people that find recovery successfully there. And when you're talking about opioid use disorder, we still know that the majority of people who suffer from that disorder will find recovery, most likely with the agonist medications.” Agonist medications are, for example, Suboxone, which activates certain opioid receptors in the brain.
And if The Healing Place methodology doesn’t work for some people, House said, “We’ll be ready with open arms to provide the treatment they need as well.”
Culp-Roche said, “If it's [Suboxone] not available, then it certainly is not going to help. So I understand where they're coming from. And respectfully disagree to some point. But again, if there are some people out there that we can help, why are we not providing it to them?”
And Culp-Roche added, some might not want a 12-step model: “Some patients will say they don't want to go because it may be more secular or religious-based, and they find it uncomfortable.”
The Healing Place has confirmed that it will allow people at the facility to receive injections of Vivitrol. Highbaugh said they support its use because “it doesn't have any street value. You know you won't find them hustling that on the street corners. So there's not as much of a call for diversion on that.”
Highbaugh and Culp-Roche disagree on the topic of MAT and opioid withdrawal.
Highbaugh said, “Yeah, no withdrawals are much worse for Suboxone and methadone and they last a lot longer. You know, so it'll add two weeks to what you would probably refer to as acute withdrawal.”
But Culp-Roche stated, “The whole point of a medication like Suboxone is to decrease the craving for the opioid and reduce the side effects of withdrawal. So if they’re taking Suboxone, they’re not going to have nausea, diarrhea, chills, those kinds of things that go along with withdrawal."
So, what ultimately made the county come down on the side of peer treatment and not MAT? When county commissioners decided to back Trillium's recommendation of The Healing Place of Kentucky over Coastal Horizons, then-Commissioner Woody White said it was about the 'efficacy' of abstinence models over MAT. Chair Julia Olson-Boseman noted "we just need to get [The Healing Place] open as quickly as possible."
Tufanna Bradley, assistant county manager and the staff liaison for The Healing Place of New Hanover County, responded to questions about not allowing MAT by noting that treatment at the facility is 'voluntary."
However, Bradley said, "If they go through the judicial system a judge could put that as part of their release. But the facility itself does not make it a requirement. Anyone could walk off the street and say, ‘I've been battling substance abuse, and I want to seek assistance.’”
Bradley added, “This is just another option for individuals who are dealing with substance abuse and want to try again at their sobriety.”
But the biggest takeaway from all those who work with people who misuse alcohol and drugs: Each individual’s journey to recovery is different. And that one should not disparage others’ paths.
