Troncale urges rejection of extreme positions on role of medication treatment

The corporate medical director at Retreat Premier Addiction Treatment Centers opened his keynote talk today at the Moments of Change conference with a somber reminder that everyone in the field can do better in combating the opioid crisis. “We've had a lot of young heroin addicts overdose after being in treatment with us,” was the frank comment from Joseph Troncale, MD.

Troncale then delved into one of the reasons why the field in general struggles to gain ground on the problem, saying most professionals are caught in the middle of polar opposite views that state either that medication-assisted treatment (MAT) is a crutch or that buprenorphine should be added to the water supply. He spent much of his morning talk at the Foundations Recovery Network conference in Palm Beach, Fla., trying to offer a sharper definition of a reasonable middle ground between two unpalatable extremes.

“Our patients need to understand that they have choices,” said Troncale. This might mean a maintenance drug for patients whose limbic system in the brain cannot be re-regulated through 12-Step attendance and behavioral techniques. But in such cases, Troncale said, “Here's a prescription, and have a nice day” is woefully inadequate care, as medication treatment must be accompanied by required follow-up and sound outpatient programming.

“There are plenty of patients who are getting MAT but are not getting evaluated,” Troncale said.

'If I were king'

Troncale structured his presentation around his vision for what the treatment system to combat the drug crisis might look like if he were in charge. These were some of his key points:

• He would have all therapists and patients trained in Acceptance & Commitment Therapy, which uses mindfulness and behavioral change strategies to encourage behaviors that are in line with the patient's values. Troncale suggested that patients' value systems are not sufficiently explored in treatment. “MAT probably won't work well if it's not in the patient's value system,” he said.

• He would train a workforce of “addiction midwives” with the capacity to visit patients before they choose to come to a clinic, modeled after the broad-based healthcare work of midwives in post-World War II Britain.

• A treatment regimen would be followed to the letter and would include regimented office visits, regular drug testing, and individualized relapse prevention approaches.

• Care providers would gather as much information as possible about the patient to inform treatment, including from family members.

• Quitting on the patient would never be an option, but there also would be a realization that the provider does not control the outcome. “Hope for the best, but understand that we control nothing” is the mantra here. “I confess that I have zero power over my patients,” Troncale added.