By Alison Knopf
Why don’t more patients go to opioid treatment programs (OTPs) earlier in their disease?
For several reasons. First, the guidelines of the Substance Abuse and Mental Health Services Administration (SAMHSA) require that patients have a one-year history of opioid addiction before entry into an OTP.
However, “history” is not well defined. “It does not stipulate frequency of use,” notes Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD).
Before SAMHSA took over OTP regulation from the Food and Drug Administration, the requirement was two years of opioid addiction. Now it’s one.
Yet, even SAMHSA is not clear on the frequency of opioid use required for program entry. Is it daily? Weekly?
“I don’t think our guidelines specify” the definition, said Mitra Ahadpour, MD, the new director of SAMHSA’s Division of Pharmacologic Therapies (DPT), in an interview with AT Forum. “We need to look at that, and if there’s is no definition for it, we need to come up with one,” she said, specifying that this should be a “collaborative effort.”
Mr. Parrino noted another reason patients begin therapy when at their most desperate, instead of early. “Patients see entering an OTP as a treatment of last resort,” he told AT Forum. “So, for the newly admitted patient, the feeling was that they were doing the best thing they could do, that this was the last stop on the train, that they’re there because if they don’t get admitted, they’ll get arrested, lose their job, OD, or die.”
This is clearly a perception problem, because OTPs aren’t only for patients facing critical circumstances. But what Mr. Parrino calls a “feeling of dread” does exist about OTPs. The patient feels there is no choice, this is the end of the line.
Then, once admitted, the patient is subject to counseling, drug testing, and dealing with clinic staff. The feeling of dread transforms to one of recovery.
The question remains, how to help prospective patients realize they can attain recovery without waiting until the last minute?
Mr. Parrino’s career started when he worked in an OTP as a counselor. “I thought I’d stay a year or two and get insight, and use it in a different setting,” he told AT Forum. “But I was genuinely moved by how patients transformed in the first several months of care, how they got healthier,” he said. “We gave them the proper dosage, they discontinued their drug use, and for those who continued to drink or use benzodiazepines or cocaine, we counseled them and sometimes hospitalized them,” he said.
Dr. Ahadpour said that the main problem is that patients and primary care providers don’t know about medication-assisted treatment, and are biased against substance use disorders (SUDs) in general. “Many primary care providers think that patients who have SUDs are not part of their patient pool,” she told AT Forum. Therefore, they don’t even bother screening for them.
Another problem is that many health care providers don’t understand medication-assisted treatment—they think of it as trading “one addiction for another,” she said. “It’s our job to bring more awareness” to referral sources, in particular, to primary care providers. “Methadone has more than 50 years of science behind it.”
The bottom line is that OTPs need to reach out to referral sources, and do whatever they can in the community of health care providers to let them know they are there to help. Education is the first step for many of these providers, who did not learn about methadone in medical school. And for patients, primary care providers and emergency departments can validate both methadone and treatment in an OTP.