MENTAL HEALTH
(continued from page 23)
federally designated program such as a methadone maintenance pro-
gram. This law revolutionized opioid addiction treatment, making
it possible for a patient to be treated in an outpatient setting, where
it was hoped there would be less stigmatization and better access.
Overall, while this treatment has been successful as a standard of
treatment for opioid addiction in many parts of the United States,
there remain significant problems with adoption across health care
systems.
Patients who qualify for OBOT are patients who have been
diagnosed with an opioid use disorder or opioid addiction, have
been evaluated by a waivered physician, and deemed appropriate
for the outpatient level of care. A qualified or waivered physician
describes a physician who has completed the appropriate training
approved by SAMHSA and who has received a second DEA num-
ber. Patients who receive OBOT for opioid addiction are found
to have less morbidity and mortality, significantly reduced risk
for overdose death, and more stable lives. The treatment does not
simply include the medication, but also involves the patient’s par-
ticipation in a comprehensive program of close monitoring. Each
is structured to address frequent comorbidities such as psychiatric
disorders, medical problems, and other psychosocial problems. The
other critical components of treatment include: determining the
appropriate level of care, providing counseling, supervision, and
monitoring that incudes pill counts with routine and random drug
testing, case management and group therapy (Boone, et al., 2004).
Office-based opioid agonist treatment is often referred to when
discussing Medication Assisted Treatment (MAT), which also in-
cludes methadone maintenance treatment (MMT), and depot nal-
trexone. MAT, which includes OBOT, has been shown to consistently
improve addiction treatment outcomes when administered under
proper medical supervision. Implementing MAT across health care
systems has been a substantial challenge that has given rise to several
initiatives by SAMHSA to address this problem, which has aimed
to provide more opportunities for providers to receive training,
education and resources to assist in implementation. Much of the
problem is related to a severe lack of qualified and available providers
who are adequately trained and prepared to address this problem,
despite the overwhelming number of patients. These efforts have
been more successful in recent years, but there continues to be a
high demand for qualified professionals, which will persist for the
foreseeable future (Volkow, Frieden, Hyde, & Cha, 2014).
Engaging patients in MAT provides an opportunity to address
the experience that patients have had with child and adult psycho-
logical trauma. Understanding that patients who are candidates
for/and seeking OBOT have high ACE scores provides a new and
different perspective with addiction treatment and can help to
improve treatment retention and overall success (Saunders, et al.,
2015). Using an overall “trauma-informed” approach has been
adopted by many addiction treatment programs and providers in
24
LOUISVILLE MEDICINE
the past several years.
The trauma-informed approach begins with educating patients
about the ACE study, which helps to normalize the patient’s experi-
ences, whereupon they often feel less stigmatized and more under-
stood. Even without meeting full criteria for PTSD under the DSM-V
criteria, many addicted patients have ongoing emotional dysregu-
lation, anxiety, nightmares, and avoidance of triggers, things that
are classically associated with PTSD. They benefit from treatments
that have been developed for this problem. Addiction treatment
programs have evolved to address PTSD symptoms more directly.
Many patients experience relief from PTSD symptoms by engaging
in a 12-step recovery program in a community of understanding
peers. Group therapy that is gender specific in addiction treatment
has evolved out of experience with the problem of co-occurring
trauma or PTSD with addiction. Addressing these problems with
patients in OBOT is critical for long-term success.
In summary, patients seeking treatment for opioid addiction
are traumatized by their addiction, and have been traumatized
before they became addicted, by their previous experiences from
childhood. Armed with this knowledge, treatment providers are in
a unique position to intervene in a way that is more empathetic and
effective; we will be less likely to react to our patients’ behaviors and
less likely to reinforce their experiences of stigma and shame.
Dr. Stewart practices addiction psychiatry at UofL Hospital.
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