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Monday Aug 24, 2015

Fresh Approach Turns Substance Abuse Challenges Into Triumphs

I practice in rural Missouri, but before I came here, I was a resident in the South Bronx. My experience in New York opened my eyes to the harsh realities of addiction and substance abuse in our inner cities.  

As a resident, I became all-too-familiar with treating patients who suffered from alcohol and opiate addiction. Still, I was not entirely prepared for the extent of the substance abuse problem I now face as a small town doc. Addiction knows no geographical or social boundaries.

On a daily basis, I must decipher the complex motives of each patient who comes into my office seeking controlled substances to treat complaints of pain, anxiety and attention-deficit disorder. I also try to determine what illegal substances they may be using.

I have found it fairly easy to identify patients who have succumbed to opiate addiction, but it is not as easy to pick out those struggling with alcoholism. After months of this struggle, I realized that I needed a program that would allow me to draw these patients out of the shadows and into treatment. I knew that an ideal treatment modality would be one that could address multiple addictions collectively, and I resolved to develop a comprehensive, integrated practice-based program that would optimize healing by addressing body, mind and spirit.

Now, with support from my hospital and the assistance of a licensed clinical social worker and office staff, we are doing just that.

We launched our addiction recovery program in April. Our focus is on maintenance of opiate (and alcohol) cessation through the use of oral (Revia) and depot (Vivitrol) naltrexone, a nonhabit-forming opioid receptor antagonist. The program is available to patients who have been able to achieve sobriety for at least seven days. They may accomplish this on their own or through the assistance of physician-guided withdrawal, a detox program or inpatient rehab. Patients are expected to enter into a recovery contract, comply with random drug screens and attend routine counseling sessions with a licensed clinical therapist.  

Many of the patients who have sought help through our program also suffer from dependence on other substances, such as benzodiazepines and methamphetamines. I have found that the medication-assisted treatment we provide, whether via placebo or through the modulation of neural pathways, along with the complementary benefits of cognitive therapy, often produces a cross-over benefit by helping our patients with their coinciding addictions.

In these early stages of the program's development, we have had some difficulties maintaining patient follow-through and compliance. Nevertheless, I have found great relief and satisfaction in knowing this resource is available to patients, and I am gratified by how easy it is to open a conversation about alcohol and opiate addiction with my patients now that I have an in-clinic treatment option.

When our addiction recovery program went live, a handful of my patients immediately enrolled, and I was pleasantly surprised by the number of referrals I received from outside my health care network.

Local law enforcement offices and family services agencies have expressed interest in working with me on a direct referral basis, which would necessitate additional credentialing for our program. This would make us eligible for state and federal funding that would cover the cost of expanding to provide a broader scope of services and to reach the uninsured. Based on the evident demand, I have taken steps toward achieving state certification. But I have done so with some hesitation because taking on such a mantle could quickly draw a greater influx of patients than we are prepared to handle.

For now, I have decided to proceed at a slow but steady pace, allowing the program to grow as a seamless part of my practice. Managing and promoting a recovery program alongside a primary care practice can quickly become a time-consuming affair, but I have managed to strike a balance that works for me, and I look forward to advancing this program as I gather resources and support.  

My passion for this project builds each week through the successes I witness and the gratitude I receive from the patients it benefits. One patient in particular comes to mind. She is in her mid-30s and has suffered most of her adult life from addiction to marijuana, cocaine, opiates, alcohol, cigarettes and kleptomania. She also has a chronic pain syndrome along with a number of other comorbidities, which I have been treating for more than a year.

It was clear that this patient was a poor candidate for continued narcotic pain management, so I presented her with the option of tapering down from her controlled pain meds and trying naltrexone. I informed her that studies had shown a reduction in overall pain level and a general decrease in addictive tendencies, particularly when paired with cognitive behavioral therapy. After discussing this option at length with the assistance of some motivational interviewing and a little coaxing from a family member and friend, she enrolled in our program.  

A week later, after her initial intake/counseling session with our licensed clinical social worker, she started medication-assisted therapy using Vivitrol. Two weeks later, this patient was back in my office reporting that all of her cravings for alcohol and opiates had evaporated and that she had less of an appetite for marijuana. She also reported that her pain levels were significantly reduced and she felt it was easier to control her urges to steal things. She continues to be an exemplary success, and a growing number of patients are making similar progress through the program.

Substance abuse is an age-old problem that, unfortunately, is here to stay. As clinicians, we will continue to find ourselves caught up in the delicate balance between appropriate patient treatment through the use of controlled medications and the hazy netherland of direct or indirect enablement of prescription drug abuse and diversion. As prescribers, we must always be on guard to protect our licenses from being taken advantage of by drug-seeking patients. However, it would be tragic if we let that fear keep us from seeking the best for all of our patients by providing help for those whose lives have been broken by the devastating consequences of addiction and substance abuse.

We have the skills and the tools to make a difference. The choice is ours. Let’s make a meaningful difference together.  

Kurt Bravata, M.D., is a family physician who practices primary care, geriatric medicine and addiction recovery in rural southwest Missouri.

Posted at 04:05PM Aug 24, 2015 by Kurt Bravata, M.D.

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