By David Moltz, M.D.*

Two years ago, after more than 30 years working with individuals and families with mental illness, I moved to a substance abuse program where I work primarily with opioid-dependent individuals.

This transition began with my work in a community support program for people with mental illness. Several of my patients also had significant problems with opioid dependence, and in order to serve them better, I became certified to prescribe buprenorphine (Suboxone).*

Buprenorphine is a "partial agonist" at opioid receptors, meaning it stimulates the receptors enough to prevent withdrawal and drug craving, but not enough to cause a high; in fact, it blocks the receptors so other opioids will have little or no effect. My patients reported that they not only had no craving for opioids, they felt as if they had never used them. The drug protected them from withdrawal and craving, and many began rebuilding their lives. This was very exciting to me, and when I heard that the local substance abuse agency was planning to start a buprenorphine program as part of their psychosocial treatment program, I jumped at the opportunity.

The demand for buprenorphine was high, and once the new program was underway my time quickly became filled with follow-up appointments. After six months, I started follow-up groups to address this. Each patient was assessed and started on buprenorphine, and then attended a "Suboxone group," first on a weekly basis, then biweekly and eventually monthly. These groups were mixed, with some people just starting buprenorphine, some in monthly maintenance, and others tapering with the goal of stopping.

Although the groups were started primarily for efficiency, it quickly became apparent that there were advantages over the individual format. I was able to see people in interaction, without their "doctor-face" on. Members were mutually supportive, and were often quite helpful to each other. They reported and validated side effects, some of which I was not familiar with; they compared experiences with pregnancy and nursing, and with having surgery without using opioids; and they talked with each other about difficulties and successes in avoiding relapse.

The treatment program had previously had very little psychiatric input, and integrating an active psychiatric presence into the psychosocial program turned out to be difficult both for the staff and for me. I quickly discovered that there were important differences between the treatment cultures and philosophies of mental health and substance abuse.

In my work in mental health, principles of collaboration and patient-centered care were fundamental. Treatment was a process of constant negotiation, and both goals and progress were determined as much by the patient as by me.

I found the substance abuse program to be much more prescriptive. Recovery, a concept that originated in substance abuse, was more clearly defined than in mental health, and in this program included total abstinence from intoxicants. Program parameters were also clear: if a person missed a number of treatment sessions, or continued to use substances of any kind, they were at risk of being terminated from the program.

Practical differences
Since buprenorphine was prescribed as part of the total program, if a person was terminated from the psychosocial treatment they also lost access to buprenorphine. I was used to treatment that was more flexible and forgiving, I believed that buprenorphine was an essential service, and even without other treatment was better than nothing at all, and I felt that I was being asked to be rigid and punitive. The staff, on the other hand, felt strongly that clear limits and consequences were essential, and in the long run were in the patients' interest. Since I was the one prescribing, they felt powerless to provide limits they believed were necessary: "Why should I take a position? He's going to do whatever he wants!"

As I struggled with these issues I came to realize that my task was to find a way to actively support program objectives without losing what I valued about my own approach to treatment. With a lot of work and goodwill on the part of the staff and program leadership, we were able to develop a resolution which accomplished this.

First, we agreed that the goal of prescribing buprenorphine was to support treatment, and it would not be continued without participation in treatment. At the same time, however, we turned around our response to problematic behavior, such as using other substances or missing treatment sessions: Instead of withdrawing buprenorphine, we increased our frequency of contact. Repeated use of opiates is an indication that buprenorphine is not working, and will lead to discontinuing. But if someone misses treatment sessions or smokes marijuana, for example, they are seen in the Suboxone groups more often. If they have been coming monthly they return in two weeks, if biweekly then they come back in one week, and if weekly, they stay at that frequency rather than progressing. This is presented as necessary to help them get back on track for recovery.

Small change has big impact
This relatively small change has had major effects. The staff felt heard and respected concerning the need for clear limits and consequences. Because I saw the consequences as caring and therapeutic, I was more willing to address problematic behavior. And surprisingly (to me), clients expressed relief that those who continued to behave outside the prescribed guidelines experienced consequences.

The difference has been especially notable regarding marijuana use. The program philosophy is that for people with addictions, use of any intoxicant makes relapse more likely and, furthermore, that real recovery involves finding ways other than intoxication for dealing with stressors; total abstinence is the goal and expectation. At the same time, it seems counterproductive to terminate useful program participation for someone who is using marijuana, if they remain abstinent from opioids. The new approach addresses that dilemma.

If someone acknowledges marijuana use, or if urine drug testing shows THC, the active ingredient in marijuana, the person is asked to attend more frequently. This has almost uniformly been accepted without protest, and has generally been understood by the individual as a sign of concern and commitment, rather than punishment. Immediate abstinence is not required, but there needs to be a commitment to working on the issue, and signs of continuing progress. Although it has not yet been invoked, the possibility of eventually discontinuing buprenorphine is still present, and continues to be a motivator. There is now a recognition that advancing in treatment is determined by personal progress, rather by the calendar. Declining THC levels, or reports of decreased smoking, are noted and celebrated in the groups, and have become a source of pride to participants.

As a result of this increased focus, there is a critical mass of participants who have become abstinent from marijuana, and are a source of support and encouragement to those who are still struggling. The group culture is now strongly supportive of abstinence.

This is a work in progress. Substance abuse treatment is challenging, and there will continue to be obstacles to working together effectively. As integrated treatment of co-occurring psychiatric and substance use disorders becomes more central, clinicians from both fields will find it necessary to rethink and adjust their treatment paradigms. This process has shown me that it is possible to work together effectively without giving up deeply held values.

*Dr. David Moltz was trained in psychiatry and family therapy. After practicing in public and private sectors in New York City for 15 years, he moved to Maine where he worked in community mental health for another 15 years. He is currently Chief of Outpatient Behavioral Health Services at The Addiction Resource Center, Mid Coast Hospital, Brunswick, Maine. Dr. Moltz is a Distinguished Life Fellow of the American Psychiatric Association, and was twice the recipient of the Exemplary Psychiatrist Award from NAMI.

Dr. Moltz states he has "no relationship, financial or otherwise, with the makers of Suboxone."

dmoltz@midcoasthealth.com