Medication as Treatment?

In this activity, participants will discuss the current debate over what type of treatment is most effective for overcoming opioid dependence. Using an article from the New York Times that reports on experiences with this approach, we will discuss the controversy over medication-assisted treatment.

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Introduction: Agree, Neutral, Disagree (10 Minutes)

  1. Present the participants with the Agree, Neutral, Disagree worksheet. Ask the audience to answer the questions and to do so individually, without sharing any responses.


Worksheet: Agree, Neutral, or Disagree?

  1. Addiction is a brain disease.
  2. Medication-assisted treatment should be offered to patients.                                                         
  3. We can trust pharmaceutical companies to produce treatments for addiction.
  4. Abstinence-based treatment should be used.
  5. Federal or state funding should be used to pay for medication-assisted treatment.


Engagement: Reading/Discussion (35 Minutes)

  1. Give participants a copy of an excerpt from In Rehab, ‘Two Warring Factions’: Abstinence vs. Medication. Ask a volunteer to read the excerpt out loud. Then ask the participants to read the excerpt individually and take notes on anything they found interesting.
  2. Once the majority of participants have finished. Bring the group back together and ask if anyone had any initial thoughts about the reading. Convene a conversation:
    1. What, if anything was surprising about the article? Did the article change their opinion on MAT?
    2. Did the experiences shared in the article match your own or second-hand experience with MAT? If so, discuss.
  3. Ask the audience to refer back to their Agree - Neutral - Disagree worksheets. Use the following questions to generate a discussion:
    1. Did anyone have difficulty assigning a position to the statements? What were some things that influenced your answers (for example, experiences, preconceived ideas, the media, etc.)?
    2. Did anyone select “neutral” for any of the statements? If so, which statements and why did you remain neutral instead of taking an agree or disagree position?
    3. Did the reading make you reconsider any of your choices? If so, which statements would change your response to and why?


Conclusion: Wrap-Up and Next Steps (15 Minutes)

  1. Announce that 15-minutes remain for the session.
  2. Summarize the main points of the discussion. What were some of the key takeaways? Were there any differences in opinions? Any controversies? Based on the dialogue, what will you be thinking about after your leave?
  3. Wrap up the session by speaking about the manuscript, further efforts, additional resources, etc. Exchange contact information and continue further conversations if needed.


Reading: Excerpt from “In Rehab, ‘Two Warring Factions’: Abstinence vs. Medication” from the New York Times.

The strong evidence for medication-assisted treatment has yet to win over not only many treatment providers, but patients themselves. Heather Ramsey, 30, who is six months pregnant, was prescribed one of the medications, buprenorphine, at JourneyPure. Addicted to pain pills and Xanax for half her life, she had finally sought treatment because, she said, “My body can’t take it no more.” Despite her doctor’s assurances that medication was the safest, surest protocol for her, Ms. Ramsey, from rural East Tennessee, feels guilty about it.

“I feel like I’m kind of, in a sense, cheating the program,” she said one afternoon in the living room of a residential cottage, adjusting her ponytail after a group meeting with a recovery coach. “Because I’m still depending on a substance to make me feel normal, and that’s not why I came here.”

Anti-craving medications are not a silver bullet; relapse is common even among people who take them, and some in fact do better with an abstinence approach. But there is substantial evidence that buprenorphine and a similar drug, methadone — which has faced ideological resistance on and off for decades — reduce the mortality rate among people addicted to opioids by half or more; they are also more successful at keeping people in treatment than abstinence-based approaches. A federally funded study last year found that naltrexone, a non-opioid medication that JourneyPure has offered to some patients since it opened in 2015, was just as effective as buprenorphine.

But naltrexone, also known by the brand name Vivitrol, is more expensive and people tend not to stay on it as long. It is also harder to start because it requires a long detox period first.

“It’s really the linchpin of our strategy going forward — I can’t overemphasize that,” said Daniel Knecht, vice president of clinical strategy and policy at Aetna. “But too often you have to convince the caregivers, as well as the patients, that M.A.T. is the cornerstone.”

Sam MacMaster, JourneyPure’s co-founder and chief clinical officer, is among the wary. He acknowledges the power of medication to “stop the chaos” that envelops the lives of addicted people, but worries it will squeeze out therapies that help them learn “how to connect, attach to other people and healthy things.”

“My fear is we are heading in the direction where it’s enough; that there’s a wholly pharmaceutical solution to addiction.”

The medication that JourneyPure and other residential treatment programs use most is naltrexone, because it is not an opioid. It blocks the brain’s opioid receptors, preventing any high in patients who try to use opioids while on it. JourneyPure typically offers patients an initial shot near the end of their stay, with the option of returning monthly for more.

At Dr. Loyd’s urging, JourneyPure has also decided to let residential patients take buprenorphine, also known as Suboxone, if he recommends it. In the past, the company had used the medication only to help detoxing patients get through withdrawal.

“These people were vulnerable, at high risk of overdosing and relapse,” he said. “We have to keep as many people alive as we can.”

“When I get a kid coming in that’s been to five abstinence-based programs, and he’s overdosed and he’s been Narcanned four times and he’s 23 years old, I am absolutely going to talk to him about medication 100 percent of the time,” he said, referring to the drug Narcan that revives people from overdoses.

“Matter of fact,” Dr. Loyd continued, “I’m going to try to talk him into it, because I know it’s his best shot at living. Yet I have people out there all the time, right now, that will throw rocks at this kid and shame him for being on it.”


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