During a four-day conference held in San Antonio, some 500 members of the National Association of Addiction Treatment Providers (NAATP) engaged in a series of detailed and decidedly clinical discussions about the surge of opiate addiction and how best to combat it. These discussions reflected efforts to bridge a once-wide gap in the organization between members who consider 12-step treatment the best hope for recovery and others intent on defining a role for medication-assisted treatment (MAT).
In recent years, news that an MAT trial was underway at a nationally known addiction treatment center was viewed as a threat by 12-step advocates, who feared several things. First, some worried that a well-known treatment provider might “sell out” by adopting MAT in place of 12-step principles in the quest for a quick buck. Second, that more patients would fail to achieve abstinence and instead rely on long-term “maintenance” medication—a profit boon to both manufacturers and treatment organizations. And third, that the apparent ease of MAT (which can be as simple as a physician visit and a long-acting injection) would lead cost-conscious insurers to push it as the preferred mode of addiction treatment, taking away from consumers the choice for more intensive 12-step approaches which define success as long-term abstinence from substance use.
But on both sides of this debate, the latest NAATP meeting showed that sentiments had softened. Evidence of this was seen in the title of a talk, “It’s not us against them!” that reasserted the role of abstinent 12-step treatment in the continuum of addiction care. In the talk, three longtime medical directors — Charles Morgan, MD, medical director emeritus of Seabrook House; Charles Sledge, MD of Cumberland Heights, and Kenneth Thompson, MD, of Caron Treatment Centers — offered a spirited discussion about the need for and merits of the 12-step approach, answering questions about its perceived limitations and identifying its unique strengths relative to MAT.
Treating “a disease of the instinct”
Morgan argued that the neuropharmacology of addiction, notably the action of substances on brain chemicals like endorphins, for example, makes addition “a disease of the instinct” that leads patients to experience a symptom of addiction — a powerful craving for opiates —with much the same force as a more basic and positive survival instinct, like hunger or self-preservation.
Referring to a spectrum of opiate addiction medications, Morgan said that “If we just block the receptor [the opiate receptor in the brain], we still have a patient with instincts that have gone awry.” He asserted that a more comprehensive treatment approach, like the 12 steps, can be essential to enable an individual to “retrain” his brain and instincts over a longer period.
Chapman Sledge, MD continued the discussion by outlining differences in the neurological activity of opioid treatment medications. While all of these meds are designed to “bind” to and “block” a neurochemical receptor site to prevent the binding of the addictive opiate, their activity varies significantly:
· agonists like methodone bind and then mimic the activity of a more harmful substance like heroin to satisfy the user’s craving. They are used for long-term maintenance treatment, which essentially substitutes a “safer” opiate for a more harmful one.
· partial agonists such as bupenorphine also bind and mimic opiate activity, but produce a weaker effect.
· antagonists like naltrexone (Vivitrol) and naloxone (Narcan) bind and reduce the user’s craving, but produce no opiate effect.
Sledge pointed out that while partial agonists such as buprenorphine, or combinations such as buprenorphine plus naloxone, are being evaluated for their effectiveness in helping individuals addicted to injected opioids like heroin, their potential for abuse is high. Citing European studies, Sledge said that the diversion and abuse of buprenorphine or bupe/nx is “common” in France, and is the most common drug of abuse in Finland.
The problem, he said, is that “people struggle to take bupe as directed.” Instead of a self-managed tapering process using a pill form of the medication, he said that patients often take too much, still seeking the more powerful effect of the opiates that they had been abusing. The result is that patients never break their opiate habit. And, should they return to the more powerful illicit opiate after a period of bupenorphine use, overdoses are common.
While 12-steppers are skeptical about bupenorphine, many see a role for opioid antagonists such as naltrexone, particularly in early-stage treatment. The medication cuts opioid cravings, freeing an individual to focus on learning and practicing recovery behaviors while withdrawing from opiates.
“A disease-modifying drug”
Kenneth Thompson, MD of Caron Treatment Centers, continued with a discussion of “modern abstinence,” which he said may employ medications as an adjunct to the goal of abstinence, but not as a substitute for it.” He called the 12-step process a “disease modifying drug” because it treats not only the physical symptoms, but its psychosocial root causes.