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Medication-Assisted Treatment (MAT) is one approach to addiction recovery with a large demographic of supporters, and a large group of skeptics. On one side you have those who insist that MAT is the best solution from a medical and scientific stance. On the other side, opponents argue that treating one drug with another is not really solving any problems, and that cognitive behavioral therapy is a better strategy. Now, some initiatives push people to meet in the middle. So is this the best way? Moreover, should states require therapy as part of MAT treatments, such as Suboxone.
New Rules for Suboxone Treatment in Ohio
For those who don’t know, the state of Ohio has consistently had one of the highest overdose death-rates per capita in America. In the midst of the opioid crisis, the Buckeye State has suffered tremendously, while officials have tried to develop new strategies for addressing the issue. Last year, the Ohio medical board proposed new rules that would apply to doctors prescribing buprenorphine.
To clarify, Suboxone is a brand-name for buprenorphine, which is one of the three FDA-approved drugs for treating opioid use disorder.
Currently, Ohio requires patients receiving Suboxone to also receive counseling. Additionally, the new rules would specify what types of counseling or therapy qualifies an individual for Suboxone treatment.
These proposed changes have been submitted to the Joint Committee on Agency Rule Review, with some suggested alterations. One such alteration allows patients who refuse behavioral therapy to instead attend 12-step groups or another self-help recovery program.
Changes are expected to be on the committee’s agenda for review on March 4, 2019. So time will tell if the new rules end up making sense for the overall new direction of opioid treatment in Ohio.
Opponents of Mandatory Counseling
While many feel that therapy is an important resource for those trying to get off drugs, several doctors oppose the requirement to get counseling. Some physicians insist that any kind of therapy is not medically necessary. Therefore, it only limits the number of doctors who can offer MAT, which subsequently limits the number of patients who have access to help.
One such physician is Dr. Jeanette Moleski, a board-certified addiction and family medicine doctor in Portage County near Cleveland. When writing to the board about the barriers in Ohio law to medication-assisted treatment, she states,
“There are a lot of barriers that we’re putting in the face of treatment. What I am afraid more rules will do is keep good physicians and other providers from even considering treating people with addiction.”
This is an understandable concern. After all, if someone is unable to receive counseling or therapy due to a lack of resources, many believe they should still have access to medically effective medications. Furthermore, doctors fear that some patients may choose to forego treatment instead of going to counseling. Moleski also asks that if a patient stays on Suboxone for years, do they need to be in counseling or therapy for years as well? Moleski points out,
“It doesn’t say how long that needs to continue. It’s very unclear.”
Reports indicate that experts on both sides of the debate believe an individualized approach is the best answer.
Dr. Moleski is not alone on this either. The Ohio Society of Addiction Medicine has also objected to requiring therapy to receive Suboxone as a medical treatment. The organization cites a 2018 Substance Abuse and Mental Health Services Administration document called Treatment Improvement Protocol 63, stating:
“Four randomized trials found no extra benefit to adding adjunctive counseling to well-conducted medical management visits delivered by the buprenorphine prescriber.”
The group echoes this area, asserting that counseling does not improve outcomes.
Supporting the Counseling Requirements
Meanwhile, there are those who support the current requirements and find the new rules will only ensure patients are receiving quality care. In fact, the same 2018 Substance Abuse and Mental Health Services Administration document also makes references to the benefits of counseling, including:
“Counseling helps people with (opioid use disorder) and other substance use disorders change how they think, cope, react, and acquire the skills and confidence necessary for recovery.”
Surely, many behavioral health experts know that medications like Suboxone can help patients avoid overdose and death by blocking their craving for opioids. However, they also know that these medications have their own risks of withdrawal, abuse, and addiction. Experts also believe it’s the psychosocial treatment that facilitates lasting change for long-term recovery.
A lot of treatment programs are abstinence-based at their core, but also accept patients who wish to utilize medication-assisted treatment. Given the growing popularity of harm reduction techniques, most treatment programs offer some form of medication-assisted treatment. At the very least, a comprehensive program will offer safe medical detox resources to help patients through the initial stages of withdrawal.
Beyond that, many feel that in order to truly overcome an addiction patients must get treatment for the underlying issues that contribute to substance abuse. Otherwise, it is like repeatedly replacing a Band-Aid to a wound that won’t heal.
Curbing Street Sales of Suboxone
Those who support mandatory counseling are concerned about doctors who operate cash-only clinics, worried that they will dish out Suboxone with no other services or referrals to further treatment simply to make money. While we would like to believe this wouldn’t happen, we have seen the damage of untethered prescribing with opioid pill mills.
Recovery advocates also indicate that some patients might sell their prescription for some of these maintenance drugs on the street for a huge up-charge. So by dolling out Suboxone without trying to regulate access in some way, a lot of those powerful drugs could end up in the wrong hands. Furthermore, if these patients are using Medicaid to fill their prescriptions, that translates to taxpayer money inadvertently funding the illicit drug trade.
Essentially, advocates believe that additionally, requirements will reduce the number of patients who abuse or illegally sell their prescriptions.
Should Therapy be Required for Suboxone?
Many people will argue that suboxone treatment is a crucial medical resource that should not be dependent on a patients willingness to attend therapy. Because addiction is a health issue, some believe the focus should be primarily on the individual’s health. Moreover, opponents of mandatory therapy believe that it is not fair to force patients into a treatment model that isn’t medically necessary.
Meanwhile, experts and recovery advocates believe that in order to facilitate long-term recovery, each individual must have an opportunity to address the deeper, more complex side of addiction. Even though the physical aspect of addiction is significant, true recovery means developing healthier coping skills, addressing emotional traumas, and treating other mental health issues. Addiction is not just a physical illness. Therefore, many recovery advocates believe there should be some other element of treatment.
Finally, we should note that even the makers of Suboxone do not recommend their medication as a substitute for comprehensive treatment. In fact, on their website one of the first pieces of information states that Suboxone is a medicine used “as part of a complete treatment program that also includes counseling and behavioral therapy.”
Treatment experts typically agree that MAT programs can be useful, but they are most effective in combination with some form of therapy or counseling.