April 26th, 2015

Five-Year Recovery Model Proposed as Standard of Treatment

While addiction is often considered a chronic disease, treatment assessments have a short-term focus. A new model of treatment outcome evaluation that calls for the assessment of patients for five years after entering treatment will be examined in a Sunday session.

Robert L. DuPont, MD, FASAM

Robert L. DuPont, MD, FASAM

“We want to lengthen the time horizon so people don’t think only about what happens to the patients when they are in a treatment program. They need to think about, ‘Then what happens?’ Now, most programs assess what is happening during treatment,” said Robert L. DuPont, MD, FASAM.

Dr. DuPont is the organizer of “Five-Year Recovery: A New Standard for Assessing Effectiveness of Treatment.” The session will be presented from 8 to 9:30 am Sunday in Governor’s Ballroom D, Fourth Floor.

The long-term approach to assessing the success of addiction treatment was developed when Dr. DuPont and two other addiction leaders looked at the State Physician Health Programs. Dr. DuPont is President of the Institute for Behavior and Health, Inc., Rockville, Maryland

“The most striking thing about addiction treatment is how frequent relapses are,” he said. “Often, they are considered a defining characteristic of the disease of addiction. A number of patients in my practice were physicians who were monitored in in the Physicians Health Program and they did very well, so I thought, ‘Let’s look into that.’ There were a number of state programs that had reported good outcomes.”

The Federation of State Physician Health Programs supported a study of 16 state programs where the standard was five years of monitoring program participants with random testing for any use of drugs and alcohol, as well as active career management, including participation in community support programs. The group also examined criminal justice system programs that had intensive long-term monitoring with serious consequences for any alcohol or drug use. Substance abuse treatment of these physicians occurred for only a few months of those five years.

“We were fascinated by the question with respect to all substance abuse treatment, ‘What happens to those people when they leave the treatment?’ What everybody wants out of treatment is to have the disease under control so it is not adversely affecting the person’s life,” Dr. DuPont said. “That standard also is what is used for cancer survival to measure cancer treatment where a standard is five-year survival.

“When you start treating a person, what is the likelihood that person will be in recovery—not using drugs or alcohol or having problems with the disease of addiction—five years later? That is a very important way to level the playing field of assessment for medication-assisted treatment, for abstinence-based treatment, and for all kinds of interventions. If five-year recovery became a standard, all treatment programs would compete with each other to get the best five-year outcomes, like various cancer treatments are compared to each other.”

Other speakers at the session have been involved in the development of the five-year model:

  • Wilson M. Compton, MD, Deputy Director of the National Institute on Drug Abuse, will discuss the brain science behind a long-term evaluation, focusing on brain changes from addiction that are long-term, if not permanent.
  • Thomas McLellan, PhD, Board Chairman of Treatment Research Institute, will discuss how this evaluation treatment model fits into health care in the United States.
  • DuPont will discuss the development of the treatment assessment model and its current status.
  • Mark S. Gold, MD, FASAM, Adjunct Professor, Washington University, St. Louis, will discuss the Physician Health Program and the study of these groundbreaking programs.

“Our paper says, ‘Let’s think about the goal of substance abuse treatment.’ We are proposing that the central goal is sustained recovery. How do we assess the extent to which any treatment program succeeds in achieving that goal?” Dr. DuPont asked. “Of course there is plenty of controversy in the field about whether this is the right goal for treatment.”

Policy Plenary Opens Debate on Buprenorphine Prescribing Limit

Countering all the positive outcomes of buprenorphine treatment for patients with addiction are the negatives of the drug’s misuse that are frequently cited by critics, including legislators who oppose expanded use of pharmacotherapies to treat addiction. Saturday’s ASAM Policy Plenary opened the door to a passionate discussion of how to address the problem.

D3-Buprenorphine Panel

(From left) H. Westley Clark, MD, JD, MPH, CAS, FASAM; Scott A. Teitelbaum, MD, FAAP, FASAM; and Mark Kraus, MD, FASAM.

The session, “Consequence of Changing the Buprenorphine Prescribing Limit,” featured H. Westley Clark, MD, JD, MPH, CAS, FASAM, reviewing facts about buprenorphine use and misuse. Then, he and session moderators Scott A. Teitelbaum, MD, FAAP, FASAM, and Mark Kraus, MD, FASAM, opened the floor to discussion from attendees, but the session ended with about a dozen people still lined up at microphones waiting to speak.

Opinions ranged from those supporting physicians being allowed to prescribe buprenorphine beyond the 100-patient limit, to those who questioned a need for that expansion, to suggestions for other options. Two themes often cited by speakers were to remember the patients and to remember what caused concerns about drug misuse.

“From my perspective, it is premature to be discussing the issue of caps. Maybe we should be talking about the quality of care,” said Dr. Clark, the former Director of the Center for Substance Abuse Treatment, part of the Substance Abuse and Mental Health Services Administration. He is now the Dean’s Executive Professor of the Public Health Sciences Program at Santa Clara University.

Dr. Teitelbaum, Professor and Vice Chair, Department of Psychiatry, at the University of Florida, also reminded everyone, “You better pay attention to the opposition and what they are saying. People are trying to do the right thing, and the reality is there is a problem out there.”

D3-Buprenorphine Crowd

Mark R. Publicker, MD, FASAM, makes a comment during the session, as other attendees line up behind him to speak.

Audience member Michelle Lofwall, MD, University of Kentucky, Lexington, said she had concerns about the lack of physicians in rural areas who had obtained waivers to prescribe buprenorphine, and suggested a compromise to the 100-patient limit.

“Maybe we need a more nuanced approach,” she said. “If we had someone at the limit, let them increase that limit when they are in a dire situation. Maybe we should be tweaking the approach.”

ASAM President-Elect R. Jeffrey Goldsmith, MD, DLFAPA, FASAM, speaking from the audience, discussed the broad patient population he has treated at a VA hospital. When it was suggested that more physicians could prescribe buprenorphine after taking ASAM’s eight-hour course, he said that was not the solution.

“I think we need to get out of narrow-minded thinking. It is not just the prescription,” he said. “People avoid going to treatment. There is a complicated set of problems. You have to appreciate the complexity of the situation and deal with it.”

Following a discussion of the time required to adequately diagnose and treat a patient, Dr. Clark offered a comment repeated during the session: “We want to make sure we don’t become the next pill mill.”

Other comments from audience members:

  • “I have concerns about lifting the limit. I work in inpatient care, and I would have trouble treating more than 100 people.”
  • “We would have fewer deaths if we could increase the numbers. Every time I prescribe, I am taking somebody away from a dealer.”
  • “Legislators listen to us, but they also listen to our patients. We need to look beyond our walls and partner (with patient groups).”