Medication-assisted treatment for opioid dependence in Twelve Step–oriented residential rehabilitation settings

Noncommunicable diseases are a major focus of attention of the World Health Organization,¹ and drug misuse is among the 25 leading causes of risk for mortality worldwide.² One recent example of this problem is evident in the United States, with a rise in the last 15 years in opioid addiction as a cause of death.³ The use of medication for treatment for opioid addiction, most recently in the form of buprenorphine and depot naltrexone, has led to a focus on the employment of medication-assisted treatment along with psychosocial approaches for opioid-dependent patients. Attention to this approach was underlined by the recent announcement by the US president of a major initiative to expand access to medication-assisted treatment for opioid use disorders.⁴ One area where consideration of this approach can be addressed is the widespread use of freestanding residential rehabilitation programs for substance use treatment. In the United States, there are 3450 such programs oriented to addiction rehabilitation that are not hospital-affiliated.

Contemporary residential rehabilitation programs for alcohol and drug use disorders originated in the 1940s with the wedding of professional care to Twelve Step–based recovery. At that time, this approach was directed to dependence on alcohol, for which the fellowship of Alcoholics Anonymous (AA) had originally been developed. It was only later that people addicted to other drugs came to be treated in Twelve Step–based facilities.

With the increase of addiction to narcotic analgesics and heroin in recent years, the issue can be raised as to whether medication-assisted treatment (MAT) can be adopted in the Twelve Step–oriented rehabilitation settings to best address the needs of opioid-dependent patients who may be admitted. This has raised concerns among some clinicians committed to AA-based recovery about the compatibility of the Twelve Step model with opioid maintenance on a dependency-producing agent such as buprenorphine, or on an opioid antagonist. This relates to a fundamental issue for them, of how the biomedically oriented and the Twelve Step approaches can be combined to yield an outcome that can be superior to either approach alone. We write here to discuss the feasibility of implementing such a combined approach in established Twelve Step–based residential rehabilitation settings, in order to achieve improved clinical outcome for opioid addicts.

Magnitude of the problem

There have been 2 related trends in the United States in recent years regarding opioid use disorders. The first relates to nonmedical use of prescription narcotics, yielding a marked increase in the prevalence of high frequency use of these analgesics and related substance use disorders.⁵ This has generated public health efforts geared at cutting back on the excessive prescribing of opioid analgesic medications by means such as state-based prescription monitoring and the development of guidelines for proper treatment of pain in substance-abusing patients.⁶

A second trend has been the transition of many people from dependence on opioid analgesics to heroin.⁷ Among people with substance use disorders surveyed, exclusive use of heroin more than doubled between 2008 and 2014, with nearly half of those surveyed reporting having moved on to heroin from nonmedical use of narcotic analgesics.⁸ Indeed, the portion of admissions for opioid dependence among substance abuse treatment admissions increased from 11% in 1992 to 19% in 2013.²

Treating opioid dependence with MAT in the rehabilitation setting

Inpatient rehabilitation units are a major resource for managing substance-dependent people in the United States, and most make use of a Twelve Step–oriented approach; some see engagement in the Twelve Step format as a primary goal following discharge. Prior to the current increase in opioid problems, the outcome of treatment in a systematically managed Twelve Step–oriented inpatient rehabilitation program had been reported to be positive.⁹ This approach has been useful for alcohol use disorders, for which medications have been found to be of some benefit,¹⁰ and for cocaine-related disorders, for which there are no medications that have a material impact on clinical outcome. On the other hand, we do have medications that provide clear-cut benefit for opioid use disorders, and their use in the rehabilitation setting is understandably warranted.

Methadone, the most widely used medication for opioid dependence, can be prescribed in state-regulated clinics. Buprenorphine, on the other hand, has been shown to be comparable in effectiveness to methadone as a maintenance medication¹¹ and can be prescribed by certified practitioners. Patient dropout while on buprenorphine maintenance, however, particularly in early stages of treatment, does remain a problem.¹² Extended-release naltrexone, also employed for opioid dependence, administered intramuscularly, has been shown to produce significantly longer treatment retention than placebo,¹³ but long-term outcome studies on this modality after the early stages of treatment have yet to be conducted. Findings among members of Narcotics Anonymous suggest that Twelve Step membership can be beneficial in achieving abstinence among opioid-dependent people. One recent survey showed that those whose primary drug problem was that of heroin-dependent individuals constituted 28% of NA members, and those with a primary problem of “other opioids,” 13%.¹⁴

Combining Twelve Step and medication approaches for MAT, however, can raise certain problems. A particularly salient issue is the difference in orientation between clinical staff who deliver Twelve Step model, abstinence-based treatment,¹⁵ many of whom are in that very mode of recovery. Additionally, there is a relative lack of experience with Twelve Step approaches within the maintenance-oriented medical community. Despite this, there have been attempts to adapt the Twelve Step model for patients in methadone clinics. For example, Methadone Anonymous¹⁶ has drawn on the Twelve Step model for rehabilitating methadone-maintained patients, but operates independent of either the AA or NA fellowship structures. Given the large number of opioid-dependent people maintained on buprenorphine, some have begun to attend Twelve Step groups, and in such cases, a positive correlation between the level of group attendance and ongoing abstinence has been reported.¹⁷

Medication-assisted treatment in inpatient rehabilitation

There has been a marked increase in opioid-related admissions in recent years in Twelve Step–oriented residential rehabilitation settings. In one such setting, Hazelden–Betty Ford in Minnesota, the portion of admissions that were opiate-related between 2001 and 2011 had increased from 19% to 30% of adults, and from 15% to 41% of adolescents. Opioid-dependent patients, many of whom had transitioned from narcotic analgesics to heroin addiction, were found to experience considerable morbidity and mortality after discharge from inpatient care, as clinically observed in numerous settings, including Hazelden.

Combining MAT and Twelve Step facilitation

The value of employing MAT in such residential settings, which employ a Twelve Step–oriented format, despite potential conflicts in treatment orientation, appears to be clinically indicated. Twelve Step facilitation (TSF), a manual-guided treatment for alcohol and substance use disorders, is a systematic way of integrating AA attendance into professional care. It has been shown to yield clinical results similar to those of motivational enhancement and cognitive behavioral therapy in the individual therapeutic setting.¹⁸ Additionally, Twelve Step approaches are employed in many, but not all, alcoholism treatment programs, and TSF findings are relevant here. In one naturalistic study, a Twelve Step–oriented program was found to provide better outcomes than one oriented to cognitive-behavioral therapy (CBT).¹⁹ It is relevant to rehabilitation in that greater duration of patient retention in TSF-based treatment has been found to be associated with better outcomes.²⁰

These findings suggest that promoting Twelve Step attendance over the course of an extended residential stay may enhance treatment outcomes because it continues to be reinforced over the course of residence there. Such residential settings may therefore be suitable for introducing MAT into an extended Twelve Step–oriented stay. A strong therapeutic alliance between patient and staff members has been shown to enhance TSF outcome,²¹ and with proper training, staff in residential settings could be oriented so as to maximize their alliance with patients to support combining a Twelve Step approach and MAT over the course of a residential stay. Furthermore, a group-based format for patients has been demonstrated to be clinically useful.²² Its use in residential settings may also be adapted for MAT.

The potential benefit in terms of long-term substance use outcome for MAT in “rehab” settings remains to be determined. The Hazelden–Betty Ford Center for Research, for example, is currently conducting a study of patients treated in this manner. The successful initiation of such a program, with appropriate orientation, depends on Twelve Step–oriented staff accepting the introduction of buprenorphine or depot naltrexone for opioid-dependent patients and on patients being willing to engage with this type of treatment. Given this, the need for reducing postdischarge morbidity and mortality of opioid-dependent people from residential rehabilitation settings, it would be advisable to implement such programmatic options more widely.