Buprenorphine prevents illicit opioid use & overdose death by tightly binding brain opioid receptors & blocking the effects of other opioids. A primary goal for addressing the opioid overdose crisis needs to be improving access to bupe tx AND also retaining ppl in treatment. 1/14
A huge problem is that ppl drop out of bupe treatment too soon: ~50% at 12 mos. Buprenorphine doesn’t work for everyone & most ppl don’t want to take medication forever, but too often ppl are forced from treatment early against their will. 2/14
Whether missed appointments, (+) urine drug tests or inability to pay, ppl are forced out of care. Is this wise? With risks of fentanyl, is this even safe? We justify this by saying that the pt failed treatment, but maybe our approach to treatment is designed to fail. 3/14
A typical protocol for office-based treatment would be that if someone struggles, they need a “higher level of care” – more visits, more monitoring, more counseling. But clamping down on people as they struggle may also push them away from care & back to heroin/fentanyl. 4/14
I make referrals to more intensive programs, but if someone is unwilling to attend an inpatient program, pick up medication from a program daily or attend groups 3-5 times a week, I’m not satisfied w/ saying, “well, sorry, there’s nothing more I can do.” 5/14
Buprenorphine only works if people take it. Long-acting injectable formulations may help with adherence, but taking away artificial barriers to medication – like requiring 100% abstinence from all illicit substances - could help ppl stay on treatment. 6/14
We need to understand why ppl drop out of treatment & address these problems. If someone prefers heroin & isn’t ready to stop, bupe probably won’t work. But if ppl can’t work or fulfill role obligations b/c they need to go to a program daily, that’s a problem we’ve created. 7/14
I do think mental health symptoms can be a big problem & I’m studying group-based bupenorphine treatment that combines mental health, peer support & medication management in one visit. But not everyone is willing to attend groups. 8/14
What I think we need is “low threshold” buprenorphine treatment that breaks down barriers to care and prioritizes engagement, retention in care & overdose prevention. We can help people reach their treatment goals over time. There is no 28 day cure to opioid addiction. 9/14
By “low threshold” I mean providers remove strict criteria about who they’ll treat (e.g. the FDA warns against WITHHOLDING treatment from ppl who use benzos bit.ly/2Pj4gcs) & continue to work w/ pts even if they’re unable to achieve 100% abstinence immediately. 10/14
Recently had 3 struggling pts finally make breakthroughs in their recovery: 1 got a dog; 1 got a new job; 1 needed family more involved. If I had stopped rx’ing bupe, would they have gone to higher-level program & reached recovery goals sooner? Wasn’t willing to take risk. 11/14
Low-threshold treatment can exist alongside other more structured programs. I do think the rules & supports of high intensity programs help some people who need structure. But there also needs to be a place for ppl who would otherwise completely fall out of care. 12/14
Diversion – when ppl sell, trade, or give away medication – is a real problem. We can’t continue to prescribe meds to ppl who aren’t taking them. But this can be monitored and managed in clinical practice. 13/14
Every day ppl take buprenorphine instead of heroin/fentanyl is a day their risk of overdose decreases. “Consecutive days abstinent” is not the only goal for recovery. We need a place for ppl who don’t fit the singular path to recovery that our treatment system has endorsed. 14/14
