The need for additional treatment capacity for opioid use disorders in all forms is urgent. In 2020, during the COVID-19 pandemic, drug overdose deaths spiked to record levels of more than 93,000, according to data from the Centers for Disease Control and Prevention.
Synthetic opioids, including fentanyl, were responsible for 60 percent of the deaths. Fentanyl is also infiltrating the illegal cocaine and methamphetamine markets causing further overdoses through these venues. Due to the need for social distancing and lockdowns, the ability of outpatient programs to provide treatment was severely curtailed and capacity in patient facilities greatly reduced.
That led to the expansion of telepractice and telemedicine.
As we come out of the state of pandemic and move toward an endemic state which presents its own challenges, we will need to employ a hybrid model of telepractice and in-person services designed to meet the needs of those who would best benefit from the latter, while maintaining the highest infection control standards.
Evidence-based research shows that substance use disorder (SUD) treatment should be provided in a person-centered manner, with as close to a completely individualized treatment environment as possible. That will require the program to arrive at a plan which best suits the individuals’ recovery goals as they enter treatment, and, during assessment, the provider will each present individual with the best fitting options. It is important to note that dispensing MAT’s incorporating this person-centered treatment protocol which is trauma-informed, culturally competent by staff sensitized to their own biases and who are well informed on how stigma issues can hamper successful recovery is more likely to guarantee successful outcomes.
As to the understanding of MATs – some providers remain misinformed about the efficacy and effectiveness of the treatment options: the antagonist Naltrexone, the full agonist Methadone, or the partial agonist Buprenorphine/Suboxone.
Based on available information, long-acting injectable Naltrexone or Vivitrol should be considered as a second-line treatment option for most individuals with OUD (Opioid Use Disorder. In recent studies Vivitrol, unlike Methadone or Buprenorphine, didn’t show marked reduction in fatal overdoses and also resulted in lower retention rates than the latter two medications. Accordingly, injectable Naltrexone or Vivitrol has been approved by the FDA mainly for relapse prevention. Methadone, Buprenorphine and Buprenorphine/Naloxone, collectively known as Opioid Agonist Therapy (OAT), should be therefore considered as a first-line treatment for most affected individuals.
Nevertheless, individuals should be informed of all FDA-approved options for pharmacologic therapy and should be able to choose among them in consultation with their healthcare provider, with any pharmacologic therapy able to be recommended based on individual circumstances (person-centered approach).
In addition to OUD treatment services, going forward, service delivery systems need coordinated effort implementing tele practice hybrid service, models deploying prevention, harm reduction (e.g., overdose reversal medication, needle exchanges, and fentanyl testing strips), crisis stabilization, same day service through an open access center, mobile treatment (particularly for rural areas) and peer outreach media campaigns and recovery centers are needed to fully address the opioid crisis.
I recommend that you follow closely the ASAM recommendations and SAMHSA CSAT relevant TIP publications and ensure that your service delivery plan is relevant, current and comprehensive.
Gideon Rabino, Consultant, Substance & Opiate Use Disorders Treatment, Prevention, Harm Reduction, and Recovery | Access Gideon’s Bio
Some references mentioned:
- ASAM for proper use and protocol pertaining to MAT’s: National Practice Guideline – OUD (asam.org)
- SAMHSA for a variety of treatment protocol which the reader needs to review and select those most appropriate for their operations: Search SAMHSA Publications and Digital Products
- NYS Clinical protocol for NYS providers and those wishing to adopt NYS like person centered/trauma informed/culturally competent/stigma aware standards as recommended: Clinical Standards (ny.gov)