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Q & A: Arwen Podesta on MAT and other components of treating OUD
Arwen Podesta, MD, ABPN, FASAM, ABIHM, is an assistant professor of psychiatry at Tulane University, as well as medical director for ACER LLC and owner/psychiatrist at Podesta Wellness. She recently spoke with Psych Congress Network about a variety of subjects related to opioid use disorder, including: the prevalence of medication-assisted treatment, tactics to reduce OUD, treatment of OUD and comorbidities, and other important components of a treatment plan.
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Watch Psych Congress Network's interview with Podesta: Part 1 | Part 2 | Part 3
A full transcript of the three-part interview is available below.
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Question: How often are medication-assisted treatments used to treat opioid use disorder? Has the rate of usage changed in recent years?
Answer: Medication-assisted treatment has been available for a long time for opioid use disorder. However, it was rarely used. In fact, less than one-third of the patients in the nine days were put on any sort of medication-assisted treatment, maybe even less than that.
The rate has expanded greatly over the past, maybe five years, with people like myself and my colleagues educating and really getting people to understand that there is availability. There are more tools in the toolbox and that’s really what we’re using is just a wealth or a breadth of tools in the toolbox.
Question: In addition to medication, what are the most important components of a treatment plan for opioid use disorder?
Answer: People suffering from opioid use disorder, especially in early treatment, really need some lifestyle management and accountability. Cognitive behavioral therapy and other evidence-based individual and group therapies is imperative to help people have a sense of improved cognition and well-being and also, to help with accountability.
A lot of people that have been struggling with opioid use disorder, whether it’s pain pills as prescribed by a prescriber, or whether it’s something like heroin, they have a lot of guilt and shame and a lot of isolation and a lot of hiding and so keeping it discreet, but also open enough that there is a sense of accountability and a sense of pride in making those changes can be incredibly therapeutic.
Question: Has awareness of the opioid epidemic helped reduce the prevalence of opioid use disorder?
Answer: I don’t think the prevalence has changed at this point. In fact, we are still seeing kind of a lag time of these changes because we’ve restricted opioid prescribing. However, we still have millions of opioid prescriptions out there on the street and in people’s medicine cabinets and we’ve only recently made those restrictions and it’s state by state. And we also have a wonderful, knowledgeable cartel or availability of heroin responding to the limitation of the opioid pain pills. And so, we have more heroin on the streets and it’s cheaper. And so, I don’t think that we’re going to see the change happen now. I think we’re planning for those stages. We’re planting the seeds and we may have a decrease because of the attention being paid to it now over time.
We are in the early stages of risk mitigation strategies and we want to treat the next generation and the next generation so that they don’t suffer from what our generations have suffered from. And so, that has to do with prevention strategies, with psychosocial early interventions for those that might be at risk, for those that have family histories of opioid use disorder, and then knowledgeable prescribing and rational prescribing down the pipeline. I think we will see it soon, but I don’t think we have seen it yet.
We need to continue what we’ve just started which is a multipronged approach from intervention, from prevention, like I said, risk, early risk reduction, from prescribing reduction, but also from a legal perspective or criminal justice perspective, decreasing the availability of illicit opioids that are out there.
Question: Are there any additional steps which you think need to be taken?
Answer: They’re started state by state and some states have been much quicker to respond. Some states have been slower. I think federally we have a lot of room to grow and my state, Louisiana, we are still working from the early stages. There have been many grants that came down federally ... most states that are suffering pretty badly have received monies from those grants and ... implementing it is the key, and it’s happening, like I said, differently state to state.
One of the imperative things to prevent future generations from suffering from this is more connection activities and more availability of afterschool programs and of all of the different activities that have been available in years past and that might be available in other countries that we’ve limited a lot in our culture, and that’s something that can help people stay more connected. Because really, the opposite of addiction, whether it’s from a genetic standpoint or from a psychiatric standpoint or just from a habituated using standpoint, the opposite of addiction is connection. And by establishing and fostering connections we’re going to have a less risky population that will, that if they use, they might not suffer into the depths of addiction.
QUESTION: Which psychiatric disorders occur most often with opioid use disorder, and can you point to any reasons why?
ANSWER: Many psychiatric disorders—depression, anxiety in particular, but also trauma, post-traumatic stress disorder and, in fact, bipolar disorder—all of those are reported to be comorbidities with opioid use disorder ... and even attentional disorder as well. Part of that is because the underlying etiology of those that are easily addicted might have a lower ability to produce or utilize dopamine and so, they might come to the table before even using opioids with lower energy or lower mood or lower attentional ability. And so, those disorders may be precursors to the opioid use disorder, or opioids can cause depression and opioid withdrawal can cause anxiety, and can cause resurgence of other symptoms, and can cause even a rehashing or an exacerbation of bipolar disorder symptoms.
One of the components that might not be a genetic predisposing factor to opioid use disorder, to risk of opioid use disorder, is trauma, and that’s the case with most psychiatric and brain disorders. Trauma can be a precursor to a risk of addiction, just like it’s a precursor to a risk of depression and other things that have to do with the chemistry in the brain. So, those that have post-traumatic stress disorder, untreated in particular, may have a higher predilection for addiction if they’re prescribed an opioid pain pill, for example.
QUESTION: What is the best approach to treating patients with both opioid use disorder and comorbid psychiatric disorders?
ANSWER: It’s imperative to approach the comorbidity of opioid use disorder plus psychiatric disorders by utilizing biological psychiatric approaches. So, look at the chemistry behind the symptoms and treat the chemistry. And so, if someone is struggling with opioid use disorder we’re looking at the opioid receptor. So, let’s use something to approach the opioid receptor to help calm it down, as it were.
And then, the psychiatric comorbidities. If they’re suffering from anxiety, depression, nightmares, bipolar, treat the symptoms. And it doesn’t matter what the etiology is ... brain chemistry changes because of the chronic opioid use disorder, or whether it’s a precursor of bipolar disorder and then the opioid use disorder began later and in withdrawal, or in treatment bipolar symptoms resurged, treat the symptoms. And then, check in frequently to make sure that all of the symptoms are treated, especially sleep, which is such a radar for people’s wellness.
QUESTION: Should one be treated before the other, or should the disorders be treated simultaneously?
ANSWER: Treat them simultaneously. There is a concept in early recovery when people are basically just trying to get their brain well enough so that they don’t constantly perseverate on getting the opioid again. So, there’s an idea that you don’t want to get deep into therapy for trauma. But from a prescriber’s standpoint, treat the symptoms. So if someone is having nightmares, treat the nightmares. If someone is having anxiety, treat the anxiety, hopefully in a nonaddictive fashion using a non-narcotic.
