“It is how you act, not what you take, that defines you as an addict.”
Much is being said and written about our current “opioid use/abuse epidemic”, “heroin addiction epidemic”, “opioid dependency problem”, “opioid crisis”, or other politically-correct term that catches your fancy. Speculation, and some good data, is abundant about causes, prevention, treatments, and consequences. Today’s blog will restrict itself just to treatment, Medication Assisted Treatment, or MAT. Outpatient MAT using Suboxone (1) has proved to be effective treatment for the disease of opioid dependency. Opioid addiction is a disease that we can treat, just like we can treat diabetes with insulin.
Many popular press articles and consultant’s reports are calling for “more opioid treatment beds”, BUT you don’t need a bed to detox from heroin dependency. In fact, most heroin dependent patients don’t even need to “detox”, in the traditional sense of abstaining from a substance for days, going through withdrawal symptoms for days, and coming out “clean” at the other end.
This cry to “increase beds” as the answer to opioid dependency sounds to me a bit like the cry to increase hospital beds in the 70’s and 80’s. In hindsight that urge looks misguided at best as we marvel today at replacing heart valves without surgery with 2 days in the hospital rather than 2 weeks, delivering high potency intravenous medications from the ICU formulary to patients in their homes, and the sprouting up of numerous networks of hospital-run ambulatory diagnostic, treatment, surgical, and urgi-centers. It is getting to the point where they barely let us lie down for some procedures before we are out the door.
Most substance abuse detox centers are based on the alcohol detox model with a bed in a protected residence, help with alcohol withdrawal symptoms by IV or IM or oral medications, IV hydration if necessary, and behavioral support. That model is NOT relevant to heroin dependency treatment, and, as we now know, it does not work very well.
Heroin or opioid detox centers could be described as “revolving doors” as revealed in numerous studies and as depicted in a recent HBO film. Studies have shown that people with substance addiction undergo an average of 3-4 detox stays over a median of 9 years before staying free of substance abuse for 12 months. Each stay may be as long as 3 weeks and cost about $550 a day. Heroin detox stays may, in fact, increase the chance of a fatal overdose for a patient since their tolerance of heroin decreases, and their “usual dose” before detox, if they relapse and take it, may be too much for them. “Recent abstinence is a major risk factor for fatal opioid overdose.” (2)
Today a heroin or opioid user seeking treatment for his disease can walk into a health care provider’s office and receive his first dose of Suboxone in as little as 12-24 hours after his last dose of heroin. That is how fast heroin “washes out” of the body. (Unlike alcohol withdrawal symptoms, like the DTs, which may not start until 2-3 days after the last drink.) Most heroin users starting on Suboxone experience only mild withdrawal symptoms like jitteriness or changes in bowel movements which can be treated with numerous oral medications “on the hoof”. They do not have to lie down. Their behavioral support system, required by all high quality MAT programs, can be initiated and nurtured “on the hoof.” After the first week or 10 days the Suboxone prescriptions (filled at the local pharmacy and covered by most insurance plans) are issued on a monthly basis while the outpatient mental health visits and behavioral support groups continue. A patient on Suboxone can be treated both medically and behaviorally for a year for about the same total charge as a 3-week detox center stay.
“Treatment of drug use does not require lying down.
Stand up for yourself!”
Our current thinking about the urgent need for more opioid treatment beds may be part of an outdated, knee-jerk response by legislators and policy makers to “do something” about the opioid crisis. Policy changes and public funds might be better focussed on effective, ambulatory Medication Assisted Treatment (MAT) rather than “more beds”.
1. Suboxone is taken daily in tablet or sub-lingual form and contains two drugs: Buprenorphine relieves pain like opioids but does not produce euphoria plus Naloxone which causes immediate withdrawal symptoms if taken intravenously or intramuscularly.
2. New England Jour of Medicine 373;22, November 26, pg. 2015, 2095-7; an excellent brief history of a century of Federal drug control.