Volume 4, Issue 3

Some Missing Points in Dr. Junig's Interview
Dennis Daley, PhD
University of Pittsburgh

Dr. Junig’s comments are well thought-out and reflect someone with extensive experience with a challenging group of opioid addicted patients. In responding to his comments, I got input from several highly experienced clinicians and physicians, psychiatrists and internal medicine specialists, who have large practices involving buprenophrine.

It is important for us to recognize that the use of buprenorphine has two sides: it helps many opioid dependent individuals who may not have sought other types of treatment (especially methadone maintenance). It is safe, can be distributed in a physician’s office, has few serious side effects, controls drug cravings, and helps the person feel better so he or she can benefit from other aspects of a treatment or recovery program (therapy or counseling, mutual support programs).

The negatives are that practices have little or no oversight by regulatory bodies, and there is abuse by a small group of physicians. One of the strengths (non-addiction physicians can develop practices to treat opioid addicted patients with buprenorphine) can also be a weakness since some of these clinicians do not have a solid understanding of addiction as a bio-psychosocial disease that often requires much more than a medicine to treat over the long term. These practices may have lax or minimal policies regarding other non-medicine interventions for opioid addiction. Patients diverting and selling pills is another common problem.

Dr. Juniq observes that “Many waivered physicians never actually prescribe buprenorphine products”. Some have also stopped their practices treating opioid dependent patients with buprenorphine due to problems with diversion, and failure of patients to engage in psychosocial treatments that are supposed to accompany buprenorphine administration. We need data to better understand this. It is not clear why patients failed to engage in the psychosocial treatments. What were the physicians’ roles in such engagement, and how strongly was such involvement recommended by the treating physicians?

There is no doubt that some physicians do not offer psychosocial treatments or offer it in a way that is not persuasive to patients. The problem is that providing only a “medical treatment” (i.e, a medication) may not promote recovery, which refers to learning to managed an “addiction” rather than just focusing on a “drug,” and making changes in oneself and one’s lifestyle. However, there are patients who take buprenorphine who work on personal change and growth despite not being in counseling; we just do not know how many. Addiction specialists generally believe strongly in the role of psychosocial interventions (counseling, mutual support programs or both) with opioid addiction. Since opioid dependent individuals often have other problems such as clinical depression, family discord, etc, counseling can help address these.

I suspect brief one-on-one counseling sessions with waivered physicians could make a difference, but in these settings it is likely that most addicted patients receive treatment in groups in which others provide support, feedback and confrontation about bad decisions. However, patients may need individual counseling as well to discuss problems or issues that they feel uncomfortable with sharing with peers in a group setting.

Dr. Junig states, “I believe patients have a right to ongoing buprenorphine treatment without time limitation.” Very important issue! The initial idea of using this medicine short term (< 6 months) has proven not to be very effective at all. I believe there is a need for a much longer period of maintenance treatment. At this time, the field is not in agreement how long a person should stay on buprenorphine for maintenance treatment. Initially, the hope was that this alternative to methadone maintenance would be a much briefer treatment.

An interesting fact is that a subgroup of methadone maintenance patients remain on this medicine for decades. The same is true for patients in treatment with some other “chronic diseases or disorders” such as recurrent major depression. Patients with this type of depression are encouraged to remain on antidepressant medications after they are in remission as a strategy to reduce the likelihood of another recurrence; they usually also receive brief support therapy as well as medications for their recurrent depression. The field needs to understand and accept that some cases of “chronic” diseases such as opioid dependence will require long-term maintenance.

At this point, I do not believe this “maintenance phase” can be put in a time frame. But I am confident that third-party payers will eventually support maintenance on an indefinite or as needed basis As has often been said, we need to stop treating chronic conditions as acute conditions with short-term episodes of care. Would a short-term treatment approach be accepted by caregivers providing treatment to patients with diabetes, bipolar illness, schizophrenia or some other condition?

In all due respect to Dr. Junig, his responses exclude two major issues with opioid addicted patients. First is the impact of this addiction on the family and concerned others. The emotional and financial burden created is often high as this addiction (like many others) creates havoc for many families and loved ones. He does not address how physicians should address this or if they should address it. And second, there is no discussion of the role of mutual support programs. While some NA and other 12-step sponsors and members are quite judgmental about peers in recovery taking medications such as buprenorphine, there is a movement in which some communities have specialty medication-assisted 12-step programs, thus making available a recovery program that has helped large numbers of people with all types of addiction.

 



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