Letters | Take the long, social view in drug treatment, Valley doc says
Published 1:57 pm Tuesday, August 23, 2011
In response to the recent articles on opiate dependency and Suboxone treatment, (Addiction’s hidden cost, July 20 and 27), a reader responded last week with the suggestion that I was not seeing the bigger picture: That for many patients, long term care is necessary to prevent complete relapse and social collapse.
My contribution, in providing background for the articles, was intended to help introduce the public to the enormity of the problem in terms of untreated patients, and to provide hope and a path to a new life. Those who are successfully placed on Suboxone maintenance are often a complete success in the short run, in that they are not driven to theft, robbery and prostitution, and often resolve problems with anxiety, insomnia, depression and pain. They are no longer at risk of dying of abscesses, AIDS, and overdoses. I look at this as a complete success in the short run.
As we gain experience with Suboxone, it is becoming clear that many who go off maintenance will relapse, and all of us who are trying to help addicts are struggling with how to maintain initial success. At this time, the limiting factor on long-term plans is not lack of vision on the part of the providers. The biggest problem is resistance from the insurance companies who pay the bills. The original studies that led to federal approval of Suboxone treatment show that patients can benefit from six months of Suboxone plus counseling.
The insurance companies often prefer to interpret this as justifying limiting treatment to six months. This is not valid logic, but they often hold to it, as treatment is expensive. In addition, appropriate government efforts to limit the illegal diversion of Suboxone have led to the expectation that even stable patients are seen monthly, forever. This is not an effective plan.
We need an acceptable way to arrange for close monitoring, with infrequent visits. By analogy, if I treat a patient successfully with an antidepressant, and if we try to reduce it, and they do not do well, it is quite acceptable to return to the antidepressant and give the patient a prescription with refills for a year, as we know it will work safely without much likelihood of diversion. All of us who prescribed Suboxone are struggling with this issue. It may be that we need to prescribe lower doses of Suboxone for maintenance, in combination with setting up specific sites to serve as monitoring stations without requiring monthly provider visits, unless there is a problem. This is now done routinely and very effectively to monitor the powerful blood thinner called Coumadin.
Coumadin clinics have largely replaced doctor’s offices in terms of monitoring Coumadin, because they can effectively test patients as frequently as necessary, and they can chase down patients who do not show up for required visits, all without requiring a doctor visit once the physician orders the ongoing program.
It’s important to remember that lack of clarity over the optimal five-year plan does not in itself argue against the initial plan of six months or more. This remains wildly successful for those who stay on the program.
Alan Johnson, MD/MPH
Snoqualmie Ridge Medical Clinic
