What would the ideal treatment plan or system for opioid use disorder look like?

Posted: 07 Nov, 2016     Replies: 10

What is the best way to bridge patients to detox/long-term treatment? Who are the critical partners for providers when treating patients for opioid use disorder and what approaches might best engage them? What is needed to develop integrated systems?



Marie Teichman Replied at 9:35 AM, 7 Nov 2016

In preparation for this week's discussion, I wanted to share some resources that might be of interest. We encourage you to share additional resources on this important topic, as well as any questions you'd like to see our panel address over the course of the week. Looking forward to a great discussion!

All resources for this Expert Panel can be found at ghdonline.org/opioid-epidemic/resources

Attached resources:

Jane Liebschutz Panelist Replied at 11:56 AM, 8 Nov 2016

Patients with active opioid use disorders who engage with healthcare present an opportunity to link to long term treatment. They may not be substance use treatment-seeking even if they are healthcare-treatment seeking. We do know that when presented with opportunity to start on buprenorphine or methadone with the intention of opioid treatment, they will take advantage of it, with high proportion initiating treatment. (JAMA Intern Med. 2014 Aug;174(8):1369-76). However, that doesn't always mean they will stick with it over the long run. In particular, the patients with the most serious opioid use disorders (e.g. inject drugs), did not benefit to even 6 months because they dropped out of treatment early. (J Subst Abuse Treat. 2016 Sep;68:68-73) We do know that the longer that individuals with opioid use disorder are engaged in treatment, the more likely they are to receive important benefits, like decreased mortality. Healthcare and substance use treatment systems need to partner to give that option for seemless transition to substance use treatment from the healthcare world.
During the transition from actively using drugs to engaged in treatment, the patient is pulled between two worlds, and may need additional supports and efforts to maintain in the treatment world. Clearly medication (and at high enough doses) to block withdrawal and cravings is a key part. But, stopping drug use often goes along with changes in lifestyle, including all aspects of ones life (relationships, housing, financial, etc.). What has not been tested but would make sense, is to have intensive navigation or social assistance in order to make the lifestyle changes that go beyond just stopping drug use. Someone who remains immersed in a life full of triggers and access to drugs is going to have a hard time stopping drug use.

Anna Lembke Panelist Replied at 4:51 PM, 8 Nov 2016

Thanks, Jane, for pointing out the importance of social assistance in helping bridge the world between treatment and the rest of that person's life. One of the reasons I continue to be a big believer in Alcoholics Anonymous and other 12-step groups, is because it can bridge this gap. AA isn't the answer for everyone, but for people who engage, I find treatment outcomes are improved because they are able to create a social sober network beyond the treatment environment. What are your thoughts on this?

Jason Lucey Respondent Replied at 6:03 PM, 8 Nov 2016

Thank you Dr. Liebschutz and Dr. Lembke for your posts. As a nurse practitioner in ER/urgent care settings in New Hampshire I have had numerous interactions where a patient either directly requests assistance in getting treatment or after a motivational interviewing session reveals a desire to seek treatment. Althogh some things have gotten better over the last few years(dedicated social worker in our ED, expansion of some local IOP programs), unfortunately barriers to treatment ranging from transportation issues to insurance coverage to lack of inpatient beds to long waiting lists at IOP's to the loss of the will of the patient because the process for getting a bed is laborious and frustrating all result in losing a window of opportunity for acute care health care providers to be the bridge to treatment. I have been interested in the emergence nationally of the recovery coach role and am familiar with projects like the Anchor Recovery project in Rhode Island (see https://providencecenter.org/services/crisis-emergency-care/anchored). We are seeing the growth of Recovery Community Organizations in our communities and have begun to see programs at Police and Fire departments that will connect a person who is looking for treatment to recovery coaches affiliated with the RCO's. However, we do not yet have a formal way of directly connecting recovery coaches to patients in our emergency rooms and urgent cares and most of our PCP offices. I am also interested in the work of Dr. D'Onofrio and others from Connecticut related to the use of bridge prescriptions for buprenorphine from the ER setting (https://www.ncbi.nlm.nih.gov/pubmed/25919527). I'd be interested to hear your thoughts on both the recovery coach role and how it can best be integrated with traditional health care settings and the role of ER providers in initiating medication assisted treatment.

Jane Liebschutz Panelist Replied at 5:28 PM, 9 Nov 2016

Dear Jason Lucey,
Thanks for your thoughtful reply. For patients with opioid use disorders, starting on opioid agonist treatment (buprenorphine, methadone) while in the ED and then linking to active treatment is an excellent option as demonstrated in the D'Onofrio paper. IOPs and inpatient beds are harder to come by because they are resources intensive requiring space and personnel. Although I am not aware that an Anchor peer recovery coach is evidence based, it seems like an excellent option.
In the era of accountable care- where healthcare institutions will benefit financially by keeping patients out of the hospital and having higher quality care, healthcare institutions may be willing to support the relatively lower costs to support recovery coaches. We have to make a business case in terms of return on investment (e.g. do recovery coaches increase engagement in treatment and decrease re-admission to the emergency room and hospital?) to get hospitals to pay attention to the value of this. IN addition, we need to expand treatment options- primary care physicians, nurse practitioners and psychiatrists all should be trained to prescribe and treatment addition with medications. That would expand our treatment ability greatly. (See another thread on that topic).
I'd be interested in other thoughts you may have.

Jane Liebschutz Panelist Replied at 6:01 PM, 9 Nov 2016

Anna Lembke
Thanks for your response about AA and 12 step groups. I think that development of a social network is a key element of recovery. And, as you say, AA and 12-step work for some beautifully. For others, it can retraumatize them or have them focus solely on their drug use, which then makes is hard to move on. So, if it works, great. But, don't expect it to work for everyone. Groups are useful in general for people because it forms healthy bonds of connection. That kind of connection is missing during periods of drug use.

Stewart Mennin Replied at 7:42 PM, 9 Nov 2016

I don't know who to send this to and would appreciate your routing it to
those who will read it and give it thought and action. The discussion
about global health is heavily weighted to treating and fixing the opioid
addiction epidemic in the US. No problem, it needs to be addressed and
there are significant technical capabilities that can be launched.
There is not much discussion or awareness as to the causality of this
problem because it is complex and the authors are not sure how to talk
about it in those terms. I propose to you that the decades of television
advertising by the pharmaceutical industry to persuade consumers to ask
their doctors to prescribe drugs for just about every kind of stress, pain,
psychological and physical ailment, has promoted and addicted a significant
segment of the television watching population to self-medicating. When the
recession hit and things got more expensive for working class people, and
when the cost of drugs rose steadily, some people had to choose between
buying medicines and other life necessities like food. When the cost of
health related issues increased, people still wanted medications to ease
their dis-ease and taking opioids makes a lot of sense under those
So now we mount a massive campaign to diagnose and treat the problem. And
the television ads continue. I didn't see this hypothesis tested in any of
the documents put forth. It is a testament to the pharmaceutical industry
that they have got national support in so many ways and are not investing
in an equally meaningful approach to restore a healthier nation.

What could be done now that's easy, cheap and effective? For every amount
of time a pharmaceutical company makes an add in whatever medium,
especially TV, they need to have equally compelling and separate ads for
living a healthy life, promoting the social good in the community and
region, and that includes children and young adults in and out of education

Something to think about in the GH forum.

Stewart Mennin
Mennin Consulting & Associates

Adjunct Professor, Department of Medicine <http://www.hsdinstitute.org>
Uniformed Services University of the Health Sciences
Bethesda, Maryland

Consulting Associate Human Systems Dynamics Institute

Professor Emeritus, Cell Biology & Physiology
University of New Mexico School of Medicine
Albuquerque, New Mexico, US

Rua Inhambu 1708 3311 Candelaria NE
Sao Paulo, SP Suite C
Brazil Albuquerque, New
Mexico, USA
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tel: 55 11 2501 8345 tel: 505 237 8250

Paul Nelson Replied at 11:34 PM, 10 Nov 2016

Does anyone have experience with a community wide, standardized Narcotic Contract implementation?

Jane Liebschutz Panelist Replied at 9:17 PM, 11 Nov 2016

Paul Nelson, thanks for your question. A couple of thoughts. One is that I would change the terminology from Narcotic Contract to Controlled substance agreement. It is not a contract in the legal sense of the word, and Narcotic is a legal term, not a medical one. That being said, a controlled substance agreement should reflect the policies of each clinical setting, so community wide agreement implementation would require that each practice have the same policies. However, standardized elements of such agreements may be feasible. I personally think that clinical policies are actually more important than a piece of paper that carries not enforcement. Just my two cents.


Shimon Waldfogel Replied at 7:16 AM, 12 Nov 2016

Hello Jane and all participants in this panel...
On other tracks of this discussion I posted brief intro to a project addressing Opioid Epidemic that will be launched soon...

A central aspect of the project is to start with a vision of what optimal care of SUD would look like including best practice and resources...
Here is link to the vision of individual care... (Needs lots of work)


Here is link to early effort at vision for system providing best practice


Here is link to overall treatment plan for Opioid Epidemic


Any further thoughts, input help will be appreciated..

With gratitude,