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Beliefs about OUD treatment challenged

Friday, November 30, 2018

Notes saying, "Limiting Beliefs Are Not Facts"

You may have heard that CIPC has recently received a $450,000 grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) to develop a web-based course to prepare Massachusetts medical school students to care for patients with Opioid Use Disorder.  Among the initial tasks for the content development team in building the Waiver Course for Massachusetts Students (WCMS) is to embrace a common understanding of what is known about effective OUD care.

One of the team members, Steve Martin, MD, EdM, is lead author on a paper recently published in the Annals of Internal Medicine, The Next Stage of Buprenorphine Care for Opioid Use Disorder [Martin SA, Chiodo LM, Bosse JD, Wilson A. Ann Intern Med. 2018 Nov 6;169(9):628-635. doi: 10.7326/M18-1652. Epub 2018 Oct 23].

The article reviews recent evidence in 7 areas: location of induction, buprenorphine and benzodiazepines, approach to relapse, counseling requirements, drug testing, use of other substances during treatment, and duration of treatment.

The FDA's initial recommendations for buprenorphine were conservative

When the FDA approved buprenorphine (SuboxoneTM) for OUD in 2002, initial recommendations for its use in treating OUD were intentionally conservative in an effort to avoid misuse.  But practitioners have learned a great deal about buprenorphine in the interim, and the crisis of OUD has presented many opportunities to assess the accuracy of early recommendations.

What Martin et al found in their research was that practices that have become common and widespread can actually be harming patients.  As the authors point out in their conclusions, “Patient safety depends on care that is evidence based, emphasizes harm reduction, has a low barrier to entry, and is longitudinal. When we shift our focus to providing individualized care that incorporates patient-centered outcomes, we can better help our patients with OUD achieve remission and lead improved lives.”

"This article should disrupt clinical practice..."

The Annals of Internal Medicine, in a strongly worded editorial, says the article, “should disrupt clinical practice and enhance diffusion, dissemination, and implementation of evidence-based treatments of OUD.”

Martin sees clear implications for CIPC work: “We were impressed to see that current evidence supports more flexibility and individualized patient care for OUD, care that is easier to provide, access, and sustain.”

 “The findings, conclusions, and recommendations of this article will form the backbone of the WCMS,” says CIPC Director, Daniel Mullin.  Dan points out that some of the findings in the paper will tend to contradict what practitioners believe they know about the successful treatment of OUD.  “Particularly with regard to counseling, many people firmly believe that counseling is or should be a necessary element of treatment.”  But the article found “A systematic review of psychosocial counseling provided with MAT found that ‘support for the efficacy of delivering concurrent psychosocial interventions was less robust for buprenorphine’.” Additionally, the authors found in a separate review that “’pharmacotherapy alone is effective treatment for opioid dependence with minimal to no drug-abuse counseling’.”  While many patients with OUD can benefit from counseling, we should not mandate counseling for all patients who are taking buprenorphine.

CIPC leading the team in Massachusetts 

Dan and Steve Martin have given several workshops across the country with a focus on overcoming hesitancy among primary care practitioners to introduce buprenorphine treatment into their practices.  They have helped hundreds of primary care team members to understand harm reduction and become waivered, expanding effective treatment for OUD.

Now with those experiences and armed with the solid review of available studies, CIPC will begin to construct a course that will be accessible to all of Massachusetts’ medical students.  The other members of the team that will put together the new waiver course are Phoebe Cushman, MD, MS, Gerardo Gonzalez, MD, and Amber Cahill, PsyD. This team will be advised by students and faculty representatives of the partner schools: UMass, Harvard, Tufts, and BU.

For more information about the MAT course, click HERE