Volume 4, Issue 3

Experience and Opinions are Valuable, But We Need Data
Michael Boyle, MA
University of Wisconsin

I usually cringe when I hear the phrase “based on my experience” as it is likely that an opinion is forthcoming without supporting data. Still I wish to share some experiences that lead me to support many of Dr. Junig’s points based on “my mistakes” as a former administrator of a substance use treatment organization. An old adage is to never tell a story without data and never provide data without a story. I apologize for my violation of this rule.

Our original use of buprenorphine was Subutex for opiate withdrawal in a medical detoxification unit. The medication was titrated over a 5-7 day period. Several problems were encountered. The available beds were being filled with opiate patients due to the length of the detox limiting availability to people in alcohol withdrawal. There was no medical reason to keep them in the detox facility other than to continue the medication through the withdrawal period. Once the detoxification was complete, many did not link to and engage in ongoing treatment and would return to use, followed by subsequent detox episodes.

When Suboxone, a combination of buprenorphine and naloxone became available, I decided to move patients to an outpatient service that would begin with a single day of inpatient care to stabilize a patient on the medication. The medication-assisted treatment would be combined with a new evening intensive outpatient service (IOP). I decided we should use a 13-day titration schedule that had been used in a NIDA clinical trial. When I told Dennis McCarty, a fellow member of The Bridge editorial board of my plans, he just shook his head and said that a short detox schedule would not be successful.

Dennis was right. When we tried to do a 13-day titration schedule there was rebellion among the patients. They were fine with lowering the doses (which also saved them medication costs) but did not want to end use of buprenorphine. A consistent theme from the patients was “I feel fine, I am getting my life back, and I am reconnecting with my family.” Thus, we switched to a plan to provide the medication for a 2-3 month period. That also was not acceptable for some of the people served, who chose to continue treatment further and go to buprenorphine-certified providers in private practice, paying for monthly visits out-of-pocket.

The initial cohort of patients also complained that four nights a week of IOP was too difficult and intrusive. Some were located a distance away from the clinic and had to drive up to an hour each way. They also wanted more individual and family sessions. Having learned the principle of “listen to your customer” from our NIATx experience, the clinical staff worked with the patients to redesign the delivery system.

The group agreed to two nights of two-hour group sessions weekly with the other evenings being available for individual or family sessions. Attendance was high. An interesting story was when a group had been scheduled for the Wednesday night before Thanksgiving, the counselor asked whether the patients wanted it cancelled. They said no and attended. They had ownership in the services.

While Medicaid covered buprenorphine in the state, no general revenue or Federal block grant funds were available to purchase the medication. Thus, we asked clients to pay for the buprenorphine and the majority who were offered the service paid for the medication. Family members were often more than willing to assist with the funding. Of course, in choosing treatment over continuing addiction, there was a cost offset between paying for heroin or prescription opiates and the cost of the buprenorphine.

I agree with Dr. Junig that we should avoid policies, rules, and laws that restrict how buprenorphine is utilized, such as limiting the length of time a person may be prescribed the medication or the number of patients a physician can serve.

While my traditional orientation presses for me to advocate that a person receive psychosocial treatment in addition to the medication, I think this should be the patient's choice, rather than a requirement. Give them a choice of evidence-based treatments offered by the medical provider or through a referral. As computer- based treatments proliferate, this provides another option to the patient.

I also appreciate Dr. Junig’s counter to some of the media horror stories about buprenorphine, such as the one he refers to from Indiana. In particular, he cites that there are only about 40 overdose deaths annually where buprenorphine is found in the person’s system. If that study was based on the total of 35,000 total overdose deaths each year, it provides important data on the relative safety of the medication.

Perhaps the most important point repeatedly made by Dr. Junig is that more data are needed. There are many conflicting opinions about the use of buprenorphine, but we need sound studies to support or counter these views, and provide physicians with all the necessary components for “evidence-based practice.”

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