Supportive Care Essential to Maximize Effectiveness of Buprenorphine for Opioid Addiction

SAN DIEGO—Medication treatments such as buprenorphine are allowing physicians to address opioid use disorder (OUD) successfully, but medication alone is not sufficient to bring about a stable recovery in patients, Arwen Podesta, MD, said at Psych Congress 2019.

Dr. Podesta, an adjunct professor of psychiatry at Tulane and Louisiana State universities and owner of Podesta Wellness, told a session audience that included current and would-be providers of medication-assisted treatment (MAT) that physicians need a clinical support team to address the full range of OUD patients' medical and recovery needs. “It really takes a lot of supportive services,” she said. “It's hard to do as a stand-alone [provider].”

Dr. Podesta's own practice, which offers both MAT and psychotherapy, includes nursing support for completing physical examinations and counseling staff for roles that include monitoring medication adherence. “Having a counselor who knows how to hand-hold a patient during this difficult time is very useful,” she said.

See the session slides here

Her talk focused mainly on considerations in becoming a waivered prescriber of buprenorphine and maximizing the treatment's effectiveness, though she also addressed the other federally approved medication options of methadone and oral or injectable naltrexone for OUD. Deciding on the most appropriate option for the individual patient must account for patient preference, patient setting (i.e., housing status), potential contraindications, and cost factors.

Whatever the medication choice, however, Dr. Podesta sees the risk of opioid overdose as so strong that she considers it unsafe for any of her OUD patients not to be on one of the approved medications. “I want that opioid receptor covered,” she said, either by one of the agonist drugs (methadone, buprenorphine) or the antagonist naltrexone.

How long in treatment?

Dr. Podesta vowed early in her session that she would be asked the question of how long a patient should remain on MAT, and indeed an attendee later asked if it was unfair to tell patients early on in their care that this might be a lifelong treatment. She invoked the frequent comparison between addiction and diabetes to point out that there is no magic answer to treatment duration for a chronic, disabling illness.

If the treatment assists recovery, it makes sense to continue, said Dr. Podesta, who added that she has worked with patients who have been taking buprenorphine for the entire 10 years she has been prescribing it. On the other hand, she said, physicians who would rush to become waivered simply because they see dollar signs clearly aren't practicing under accepted guidelines.

She reminded the audience that buprenorphine prescribers under the Drug Addiction Treatment Act (DATA) of 2000 face regulatory scrutiny on a number of fronts, including possible site inspections by the Drug Enforcement Administration (DEA).

Dr. Podesta, who recently joined the Psych Congress Steering Committee, offered this guidance for avoiding problems:

• Approach DEA inquiries as an opportunity to educate, and don't assume a defensive posture. “Your job is to educate them on the disease of addiction and why you are using medication,” she said. “Know that you're the one with the knowledge and education, and take it from there.”

• Consistently monitor state prescription drug monitoring program (PDMP) data for any signs of problems for patients being treated. Some insurance plans require these routine checks of PDMP databases.

• Refer to clinical guidelines for prescribing from groups such as the American Society of Addiction Medicine (ASAM). Dr. Podesta made special mention of the Substance Abuse and Mental Health Services Administration's Providers Clinical Support System (PCSS), which includes clinical protocols for challenges such as how to transition a patient from one medication option to another.

—Gary Enos

Reference

“What you need to know about buprenorphine treatment for opioid use disorder.” Presented at Psych Congress 2019: San Diego, CA; October 3, 2019.