The last 25 years have seen breakthroughs in treating the disease of addiction that historically baffled doctors and scientists for millennia. Absent from these advances in treatment, however, has been the sharing of information, development of standards and coordination among allied health services that is ubiquitous in treatment of other major chronic diseases like heart disease, cancer and diabetes.
We find ourselves as a treatment community in this situation in large part based on how treatment for addiction started. Individuals suffered in silence and shame anonymously and found help from other people suffering. This was the basis for Bill W and the founding of AA.
The torch for treatment was then taken up by countless others in the behavioral space to treat the psychological aspects of addiction with residential and outpatient programs of varying intensity. The medical side of care lagged behind, as providers only had “comfort” medications to treat the withdrawal symptoms.
Then we saw medical leaders like Dr. David Smith, who founded the Haight Ashbury Free Clinic to help patients suffering from addiction in his community. Dr. Smith went to the AMA and was ultimately successful with the help of others in getting addiction medicine recognized as a legitimate medical subspecialty.
Since that time, we have had a growing research basis in receptor pharmacology that impacts addiction physically. This drove pharmaceutical research which resulted in a number of medications currently available to assist patients in their journey to recovery.
Mathematically, addiction affects as many people as the “Big 3” and is now the leading cause of accidental death in people under the age of 50 – the scope of the crisis warrants urgent and smart coordination, cooperation and innovation. However, many in the treatment field or industry stakeholders simply focus on their own vertical niche while the body count rises. The most glaring example of the deadly siloing is the advent of new medications that help a patient manage opioid (and alcohol) cravings. These can be prescribed by a primary care physician with no real requirement that the patient participate or complete ancillary services such as psychological counseling, group therapy, peer group work and a lifestyle assessment. In office based prescribing, the physician is expected to encourage the patient to seek counseling, but there is no consequence if they fail to do so.
A diabetic can use a pharmacopeia of medications to manage their blood sugar – but it’s widely understood and accepted that no responsible doctor would prescribe a diabetic an insulin replacement drug and simply wish them well with fingers crossed! Successful diabetes care includes a nutrition assessment, meal planning, exercise regiment, eye exams and whole checklist of steps unique to the patient. A diabetes diagnosis is always part of any discussion with a health care provider should a patient undergo surgery or needs a prescription for another illness. Even planning a vacation must take diabetes into account.
With addiction, it should be the same. This disease is a factor in ALL health care decisions the patient will make for their lifetime. Thus, continuity of care is critical. It requires planning and a comprehensive arsenal of additional services. And like diabetes, is very deadly if mismanaged or medically underserved. Treating a craving by relaxing or blocking a receptor in the brain is much like using a spare tire after a flat. It will get you to the garage, but you still need a whole new tire. Failure to treat the anxiety, depression and other psychological elements that either cause or result from addiction will simply make a relapse a matter of time. Cravings do not exist in a vacuum – they ALWAYS include the collateral damage of mental health consequences. If you fix the hardware, you must re-load the software when treating addiction. My urgent thesis in simple language is that any gap in services can be death sentence for a patient.
I have spent a large part of my adult life working at bettering the concept of “Medication Assisted Treatment.” I started my career working on the pharma side developing and launching various pharma-therapies that help treat the powerful cravings which seem (and often are) insurmountable for those suffering addiction. Most of my work was related to opioids, but I have also worked with pharma-therapies for alcohol and stimulants.
It has been my experience that even a well-intended administration of a prescription to stem cravings without a comprehensive treatment plan which included clinical behavioral health services has increased a patient’s chance for relapse and in many cases resulted in death. Medication alone isn’t treatment ― it’s treatment preparation. It clears the patient’s mind to allow them to begin the real work of recovery with a behavioral health program. It’s confounding that any doctor wouldn’t want as broad and inclusive an approach to treating addiction as possible.
But there remains a lack of consensus in the conventional medicine community as well as the treatment field about which solutions work. It’s usually based on the professional’s subjective life experience. It’s been allowed to flourish and obscure data and create “alternative facts” that have cost lives and hindered progress. Addiction is the health care equivalent of global warming – a cacophony of stakeholders on both sides are furthering agendas that bolster their niche and ignoring inconvenient truths that are evidenced by big data and basic research.
I am working for a day when no prescription for bupenorphrine, Vivitrol, Naltrexone, methadone, Campral, or Antabuse is written without a compliance mandate that the patient receive intensive outpatient services consisting of clinical behavioral health services and evaluation and a full lifestyle assessment. This can be done through a variety of checkpoints – whether it’s insurers or agency oversight – and each health care provider in the patient’s chain of care must coordinate and collaborate in the same way we treat cancer.
Ideally, comprehensive services should exist under one roof, and licensing of treatment providers could increase its requirements and accreditation process to mandate that patients get the continuum of care they need. This isn’t hard. It can be done cost effectively and the savings in the long run of relapses prevented and lives saved would be staggering.
I take this position of solemn advocacy because I have been witness first hand to the inadvertent results we are dealing with now in every community. I was on the team that launched Suboxone into the world in 2003. With the best of intentions, we created a pathway for patients to get a prescription from their primary care physician to help with opioid cravings and lives were saved. These efforts created a new tool in the treatment of opioid addiction and saved countless lives at that time. But the overarching idea was to change the paradigm and build a bridge between the primary care physician and the treatment world. That bridge has yet to be completed.
Everyone in this space is trying their best to help patients, but many seem to have difficulty embracing the other side. We are now plagued with diversion and abuse of Suboxone, compliance problems which ill equipped primary care physicians are left to handle. All this is evidenced by an ever-increasing death toll and resistance from insurers who see an uncoordinated failing treatment field as poor ROI and justification for low reimbursement.
The most recent Director of National Drug Control Policy, Michael Botticelli, is in long term recovery, and instead of using the historic vernacular name for the post – “drug czar” ― he called himself the “recovery czar” as he advocated a national movement to nurture disease treatment over interdiction. Chief among these priorities was coordination of services and alignment of Medication Assisted Treatment with clinical behavioral health services such as counseling and intensive outpatient programs. It is unclear what the future of that White House executive office will be, how much resources will be available or what the policy positions are that will take priority. Cuts are expected. But what is crystal clear is that every day that goes by, 91 more people die from an opioid overdose, according to the CDC. The indecision and failure to act combined with the gap in services are as deadly as the drugs themselves…
When we say the words “Medication Assisted Treatment,” we are using an inseparable phrase that clearly states the medicine is a tool in the larger concept of treatment – a lowercase m and a capital T would be a visual metaphor. The services are as inseparable as the phrase and we must reframe how we see paradigm of treatment to combine the best of 80 years of spiritual dogma, 50 years of behavioral health doctrine and 40 years of pharmaceutical protocol to deploy the only effective weapon against our leading cause of accidental death – a full continuum of care. Our loved ones deserve no less.
About the Author:
Chris S Hassan, CEO, Soft Landing Recovery - Mr. Hassan joined Soft Landing in 2016. He is a Senior Healthcare Executive with over 25 years of experience in the field of healthcare. Prior to coming to Soft Landing, Chris co-founded Reckitt Beckiser Pharmaceuticals creating the office based treatment model for opioid dependence and launching Suboxone[R]. Subsequently, he served as the Chief Executive Officer of Colonial Management Group- the largest chain of opioid addiction treatment centers in the US. He also developed and patented a number of new opioid product combinations focused on preventing diversion and inadvertent benzodiazepine overdose in patients.