May 1st, 2017

New England battles opioid epidemic

Justin Enggasser, Ph.D., section chief of substance use disorder treatment services at VA Boston Healthcare System, and Boston University assistant professor.

A 2014 Health and Human Services report issued some troubling statistics for four New England states: Massachusetts leads the nation with most opioid-related visits to hospital emergency rooms – 450 for every 100,000 residents – out of 30 states providing data. Rhode Island had 298 visits; Connecticut, 255; and Vermont, 224. Efforts to address the opioid crisis have resulted in the creation of new and enhancement of existing programs at several hospitals across New England.

Christopher Cutter, Ph.D., director of the chronic pain and recovery program at Silver Hill Hospital, New Canaan, Conn., reported that this 28-day program treats patients with chronic pain issues and co-occurring opioid dependence.

Some patients come to the program when recreational use becomes an addiction. “[When] they get clean, they realize they have unrecognized injuries from years of taking opioids. They feel they’re sucked back into taking opioids again to manage the pain,” he said.

Alternatively, addiction may begin when pain, “a sensory, emotional experience,” requires medication. “But the pain signal continues to fire and the body can’t heal. So the patient treats the pain as if it’s an acute injury and becomes addicted. They find it hard to manage life,” Cutter said.

Treatment at Silver Hill incorporates several strategies, including group and/or individual cognitive behavioral therapy integrated with acceptance and commitment therapy.

“We also provide individual physical therapy for all patients. A lot of them want to get their body mechanics straightened out,” Cutter said. The program also incorporates yoga, acupuncture, exercise and nutrition counseling.

A clinical psychologist who specializes in working with opioid dependent patients works with a pain management physician and addiction psychiatrist, according to Cutter. “And family therapy is rigorous inside the program,” he added. “We talk to family members to educate them on dependency. The family has to understand enabling behavior as well as patient manipulation.”

Rick Barnett, Psy.D., LADC, private practitioner in Stowe, Vermont, agrees that family participation is as important, if not more important in some cases, to successful treatment for the individual with opioid addiction.

“If family is willing to be involved, it maximizes the chances of the person with an addiction of getting well. Family therapy is a very related, yet separate, therapy for this population that is often overlooked,” he said, noting two elements in family involvement. The first component comprises education regarding the clinical and practical aspects of addiction, how to stop enabling the patient, set boundaries and offer love and support without over-reaching or exerting control.

The second factor is directly related to the family’s needs and how they have been negatively impacted by the patient’s addiction, Barnett said.

Abstinence-based programs are still the majority in the U.S., although harm reduction via Medication-Assisted Treatment has become “the philosophy of choice” in the last 15 years, according to Barnett.

“[This] includes methadone and buprenorphine as opioid maintenance medications, but also Naltrexone – both oral and the Vivitrol long-acting injection which can last up to one month – which blocks opioids from activating receptor sites and thus blocking the effects of opioids,” he said and added Probuphine, a subcutaneous implant delivering a steady flow of buprenorphine over six months, to the list.

However, there is no “one-size fits all” approach, despite the massive promotion of medications to treat withdrawal, cravings or to block euphoric effects of opioids, Barnett noted.

He said that a “…thorough evaluation protocol, extensive educational and consent process and a collaborative agreement between patient and provider…” constitutes optimal treatment. He also advocates for a combination approach that offers medication and counseling.

The VA Boston Healthcare System has been providing a full spectrum of services that include medically supervised detoxification and comprehensive evidence-based rehabilitation and treatment services for drug and alcohol issues as well as co-occurring mental health and medical conditions for decades, according to Justin Enggasser, Ph.D., section chief, substance use disorder treatment services and assistant professor at Boston University School of Medicine.

VA residential programs provide CBT-oriented work to help patients cope with cravings and reduce depression and anxiety.

Dialectical behavior therapy focuses on emotional regulation skills and Seeking Safety, present-focused therapy, helps those with trauma/PTSD and substance use disorders.

The VA offers two programs for women: the Women’s Transitional Residence Program (TRUST House) and the Women’s Integrated Treatment & Recovery Program; special programs for men include Transitional Residence Programs in Brockton and in Boston, and the Homeless Domiciliary (REACH – Responsibility, Ethics, Attitude, Choices and Health), according to Enggasser.

One of the VA’s newest programs opened in 2011 and has proven to be successful. The Center for Integrated Residential Care for Addictions provides group and recreation therapy; mental health assessment and diagnosis; medication evaluation and management; educational groups; referrals for medical care; and discharge planning for male and female veterans.

Enggasser reported that the completion rate is “in the 80 to 85 percent range.” Rehospitalization rates three months post-discharge are 15 percent and abstinence is typically 90 to 95 percent, he added.

Patients in residential programs receive overdose prevention education as well as the option to receive rescue kits that contain Narcan, Enggasser said. “Our AEDs have Narcan in them so we can respond quickly,” he adds. “We’ve increased the number of providers waivered to provide buprenorphine and are in the middle of an initiative to give injections in inpatient units.”

Enggasser noted that the VA’s extensive outpatient services enable veterans to “graduate through different levels of care” within a time frame driven by patient needs. “The patient could be in the outpatient clinic for weeks or years as needs change and stability changes,” he says.

Enggasser pointed out that addiction is much deadlier now. “We lose patients more often than 10 years ago. The recent sharp increases in opioid use and overdose over the past few years can be attributed to the increasing prevalence of cheap and powerful fentanyl hitting the market. Many previous users of other types of substances have shifted to use of opioids because of their prevalence, low cost and strength,” he said.

Barnett is a strong proponent of better education – for society, for professionals in all disciplines from business to the criminal justice system, from healthcare providers to social services workers. “There is too much misinformation out there about opioid addiction and its treatment that must be corrected in order to decrease death rates and prevent new onset opioid addiction,” he said.

By Phyllis Hanlon

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