Lee Tetreault:

Welcome to the frequently asked questions from the session, pharmacologic management of opioid and alcohol use disorders in the outpatient setting. We are joined by Dr. Levounis. Doctor, would you like to go into some of the frequently asked questions that you have on this topic?

Dr. Levounis:  

Yes, thank you for having me for this program here. One of the most frequently asked questions I get is, "How effective are these medications for the treatment of addiction?" And unfortunately, there's not a very easy answer to that. We have to think of it in three major buckets, three major sets of addictions. There are some addictions for which we have very good medications, safe, effective, they make a big difference in people's lives. And these addictions are opioid addiction and tobacco use disorder. These are the two major addictions for which who have done very, very well. And pharmacologically, who have made it. Then, we have a category of addictions for which are pharmacological interventions and social. And the major addiction is in that category is alcohol. We do have three FDA-approved medications for alcohol use disorder, and they're fine, they're good, I use them all the time, but they're not gonna change a patient's life just by themselves. You do need to have psychosocial supports, or quite often AA, some counseling, psychotherapy for the medications to do their job.

And then we have a third category of addictions for which our medications... We don't have any medications really to offer. Primarily the stimulants, cocaine, crystal methamphetamine, cannabis, the hallucinogens, all these. The behavioral addictions like gambling, sex, the internet, all these addictions for which we do not have any medications to offer to our patients, but we do have wonderful psychotherapies and counseling that help our patients stay sober. So bottom line here, if your patient suffers from opioid use disorder, or from tobacco use disorder, you absolutely need to give them medication. Buprenorphine is the first line treatment for opioid use disorder. Varenicline is the first treatment for tobacco use disorder, and these medications are strong enough that they can carry a lot of burden of illness on the shoulder and change a person's life.

I am very disappointed and disheartened when I hear things like, "I'm only gonna give my patient buprenorphine if she or he also agrees to come to groups, or only if she or he also agrees to go to a 12-Step program." If they do, fine, great, that's wonderful, but don't withhold medication, especially for opioid use disorder, and tobacco use disorder, because your patient does not want to also engage in psychosocial supports. The medications are strong enough to change a patient's life. Primarily, buprenorphine for opioids, and varenicline for tobacco. Another question that I get quite frequently is, "How long? How long do I keep my patient on, let's say Buprenorphine, for the treatment of opioid use disorder?" And we don't have very good data to answer that question, but I would say that some people will need to stay on medication for a long, long time, if not for the rest of their lives. Not unlike people who suffer from insulin-dependent diabetes, and they do need insulin to sustain a normal life.

In a very similar fashion, there would be some patients... I don't know, 20%, 30% of our patients with opioid use disorder who may need to stay on buprenorphine, on agonist, or partial agonist treatment for a long, long time, if not for the rest of their lives. This being said, I would say that the minimum time that somebody should be on buprenorphine or methadone for the treatment of opioid use disorder is one year. What happens in one year is that patients go through all their little hells of life, graduations, vacations, Thanksgiving, holidays with parents, all the incredible stressors that they'll have to go through.

So at the end of one year, you have pretty good data to base the next level, the next step in the treatment of the patient. So, essentially after a year on buprenorphine, I may very well have a conversation with a patient, "If you really, really want to get off the medication, let's give it a shot, let's give it a try." And of course, in general, the longer the taper, the greater the chance of success. There's a little bit of controversy on that issue about Buprenorphine, specifically. But, in general, patients who have mild tapers tend to do the best and that is true of benzodiazepines as well.

Another question that I get often is the interaction between AA and medications. There is that perception that Alcoholics Anonymous is against all medications, and that is not true. Yes, the tradition in Alcoholics Anonymous may have not been the most supportive for medications in general and pills in general, but in 2019, AA does accept medications. Patients being on antidepressants, antipsychotics, antihypertensives, all kinds of medications that they needed to stay safe and stay healthy.

This being said, the old idea that if a medication is prescribed by a physician or a nurse practitioner or a physician assistant is okay with AA, has eroded because of the opioid epidemic. As you very well know, the opioid epidemic was started from our over-prescribing to our patients. So, just because someone gets a prescription for a medication, doesn't mean that it's a good thing. So, in general, AA is accepting of medications patients may have for the treatment of their alcoholism or for the treatment of comorbid psychiatric or other medical conditions.

Another question that I get is about, what do we do with having so many patients who need buprenorphine for the treatment of opioid use disorder and who don't have enough prescribers in the community. It's a major problem, and what we're experimenting with now is group treatments, group prescribing. It started in West Virginia by a wonderful psychiatrist by the name of Rolly Sullivan and has been adopted in many different parts of the country where we'll do a group psychotherapy with prescribing at the same time to a number of different people, buprenorphine. Of course, if somebody has a complication, if somebody needs extra attention, we also see them, individually. But this is one way of addressing this very real problem of not having enough buprenorphine prescribers in the face of a massive opioid epidemic.

Lee Tetreault:

This is great information, Doctor. Thank you so much for your time.

Dr. Levounis:  

Thank you.

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