Sharing Thoughts on a Panel Discussion at MOC 2019

In my role as a Clinical Outreach Professional for Futures, I feel it’s vital and rewarding to remain current with the conversations our industry is promoting to the end goal of better treatment. As a professional resource to others, I know and appreciate the complexity of addiction, substance use disorders, and the variety of interventions and modalities that exist. In a recent presentation at Foundations’ Moments of Change this week, three overarching philosophies were the topic of healthy conversation amongst professionals in our field.

Abstinence

Dr. Brian Samford of The Arbor Behavioral Healthcare in Texas led the session through a description and preference for an abstinence based approach to treatment and spoke in detail of the internal motivators driving impulsive behaviors. One of the more provoking thoughts spoke to the challenges the abstinence philosophy faces and its perception as “outdated or antiquated” as more and more scientific study is conducted and evidence collected on alternative modalities, like Medication Assisted Treatment. On a professional note, he did openly state he would consider the use of Vivitrol and Campral as viable and complementary to a treatment plan for specific cases. In closing, he shared his overall belief that substance use disorders and their treatment will inevitably become a part of the mainstream medical and healthcare realms. Abstinence based approaches may need to adapt to remain viable for those individuals and families seeking programs with that philosophical preference.

Harm Reduction

Linda Lewaniak LCSW, CAADC of Sacramento, CA based Insight Behavioral Health Centers educated the audience on her perspectives of policies and programs that support harm reduction as an intervention and treatment philosophy. A public policy effort that has roots back to the 1980’s, the goal of harm reduction was to reduce the adverse consequences of substance abuse – death, crime, and resultant declining property values. The most common form is a needle exchange to reduce the rise of infectious diseases and the most controversial form would be any safe-injection site program established to curb fatal overdoses. Interestingly, Linda referenced motivational interviewing as a harm reduction intervention meeting patients where they are and creating internal desire to promote changed behavior. Further information and education was delivered on harm reduction’s careful incorporation of the stages of change – precontemplation, contemplation, preparation, action, and maintenance. Ideally, the harm reduction philosophy allows for an “open door” along any stage of change if present in someone’s lives. Simply stated, but I enjoyed her quote “harm reduction is a place to start, not a place to end treatment.” In fact, personally I don’t really consider any “end” to treatment. Importantly, Linda also highlighted the prior separation of addictions from mental health disorders in the 1980s as analogous to the current separation of abstinence and MAT programs and suggested the two schools of thought could benefit from a philosophical merger. She reassured the attendees that the increased focus on the epidemic and conversations will most likely emphasize the need for better and more elaborate collaboration and documentation of outcomes to push our industry forward.

Medication Assisted Treatment

Dr. Carlos Tirado, MD, MPH, Founder of CARMA Health in Austin, Texas rounded out the panel by covering Medication Assisted Treatment or MAT. Per his definition, “MAT is an incorporation of safe medication to ameliorate acute symptoms of substance use disorders and create more functional states for the patient”. He described three distinct branches of MAT: 

• Substitution: Methadone, Suboxone, Nicotine replacements
• Blocking: Vivitrol, Naltrexone
• Reward Modifier: Antabuse, Naltrexone, Campral, Chantix

From his perspective, MAT has gained significant acceptance amongst practicing medical professionals as a preferred protocol for the treatment of alcohol and opioid dependence. He relayed that appropriate patient profiles for MAT include the chronic relapser, those with prolonged history and severity of misuse, those with prior overdose or hospitalization episodes. He shared a quite personal perspective that he would first seek out an abstinence based treatment for one of his own family members, but that if they experienced a relapse episode he would likely suggest incorporating a MAT protocol. Like many of us, he shared the belief that medication alone will not provide the optimal outcomes our society desires. Dr. Tirado spoke of the innovations we’re likely to witness, including longer-term injectables and unobtrusive, wearable monitoring systems with increased public funding to curb the epidemic.

My Perspective

This panel was heavily weighted to discussion on the benefits of MAT, but never ultimately answered any questions related to substantiate what the goals for patients referred to MAT programs are. There was little discussion on what a detailed MAT protocol could or should look like, but there was a shared success story of an individual who has received consistent methadone treatment for 12 years. Residential treatment facilities, like Futures, typically administer medications to safely stabilize patients with the goal of tapering the patient to be free of any medications required to assist with physical cravings or withdrawal symptoms. I am extremely supportive of meeting individuals where they are along the change of stage lifecycle and certainly open to any intervention that may provide the impetus to a healthy lifestyle. As a person in long-term recovery, I also know individuals will most often seek the easiest way and fear that non-integrated MAT programs are delaying the inevitable hard work of what I consider true recovery. There was also no mention of the difficulty of withdrawal symptoms and detoxification process when an individual chooses to stop relying on substitution medications, such as methadone and suboxone. The term evidence-based is widely promoted, but believe we require more general education and consumption of that evidence to support better treatment and outcomes. I believe the government wants to reduce fatalities, increase property values, and reduce crime but think we should avoid any type band-aid or short-term solutions to the behavioral health crisis we face today.

Special thanks to Matt Feehery for moderating the panel discussion.

John Egan, Clinical Outreach Professional at Futures Recovery Healthcare