The Worcester Physician and Buprenorphine speaker’s view of addiction treatment expressed in his recent commentary posted on Join Together (It's Time For Physicians To Support The Maintenance Model, 3/10/06) is somewhat narrow.¹ There are a number of therapeutic modalities available for consideration.² Addiction can be considered a chronic disease often characterized by episodes of relapse and remission.³ Studies such as Project Match highlight the importance of taking the patients’ goals into account when designing a treatment plan.⁴ Most addicts who seek treatment would like to live a sober, healthy lifestyle. Complete abstinence may be the preferred goal of most programs but in truth, most patients are at risk for episodes of relapse that require re-treatment. As with other chronic diseases, maintenance medication can be effective in some circumstances.

The few studies that have been done regarding the natural history of opiate addiction suggest that the largest segment of the surviving population of this lethal disease do achieve sobriety (22%). A much smaller group requires long-term maintenance medication (6%).⁵ Whatever path is taken, addiction treatment requires long-term rehabilitation with extended periods of outpatient treatment. In most cases in treating addictions, medications serve only an adjunctive role to the long periods of rehabilitation necessary.

For purposes of treatment it is necessary to be able to follow an objective measurement of maintenance medications and drugs of abuse in order to assure proper program compliance.⁶ The prevention of diversion is an important public health goal that every treatment program should honor.⁷ Urine toxicology for Buprenorphine is now available. Since it commenced urine testing, National Toxicology Services has found positive results in more than 5% of patients.⁸ Patients confirm by history the easy availability of Buprenorphine on the street.

Patients considered for office based Buprenorphine therapy must be carefully selected using evidence based criteria.⁹ Treatment structure and length requires clear explanation. The expectation of the treatment plan and desired outcome must be clearly communicated including: rules of the program; proper supervision; fees; waiting lists; investment of time; chances for patient’s input into treatment plan; and other logistical aspects of the program that may affect patient satisfaction. When patients are encountered for whom Buprenorphine appears to be the proper matched therapy, they should be referred to programs that not only have these characteristics, but also have the proper safeguards in place to prevent diversion.

The maintenance model is an excellent harm reduction strategy decreasing overdose deaths, crime, and HIV transmission in patients with a heroin, prescription painkiller addiction, or both. This model, however, can potentially sell the addict terribly short, if it is invoked before the option of sobriety maintenance is fully explored. A treating physician must always have his or her patients’ best interests in mind.

Dr. Kishore is a practicing physician specializing in Addiction Recovery in Massachusetts, and is the Founder of The National Library of Addictions.

References:
1. Jeffrey Baxter, M.D., It’s Time For Physicians To Support the Maintenance Model, www.jointogether.org, March 2006. 

2. The National Institute on Drug Abuse (NIDA); The National Institutes of Health; The U.S. Department of Health and Human Services; Principles of Drug Addiction Treatment: A Research Based Guide, Last updated February, 2005. 

3. A. Thomas McLellan, PhD; David C. Lewis, MD; Charles P. O’Brien MD, PhD; Herbert D. Kleber, MD; Drug Dependence, a Chronic Medical Illness, JAMA, 2000 – Vol 284. No. 13: 1689-1695. 

4. Project MATCH Research Group, (1993), Project MATCH: Rationale and methods for a multisite clinical trial matching patients to alcoholism treatment, Alcoholism: Clinical and Experimental Research, 17, 1130-1145. 

5. Yih-Ing Hser, PhD; Valerie Hoffman, PhD; Christine E. Grella, PhD; M. Douglas Anglin, PhD, A 33-Year Follow-up of Narcotics Addicts, Arch Gen Psychiatry/ Vol 58, May 2001, 501-508. 

6. Pilar Draman, The Council of State Governments, Trends Alert-Critical information for state decision-makers, Prescription Drug Diversion, April 2004.

7. Federation of State Medical Boards of the United States, Inc., Report of the Center for Substance Abuse Work Group, SAMHSA, April 2002.

8. Personal Communication, The National Toxicology Services. 

9. Stoller KB; King VL; Clark MR; Brooner RK. Office-Based Buprenorphine Maintenance: Setting the Stage for Success. Adv Stud Med. 2006;6(3): 124-134.