Treating heroin addicts poses a serious challenge for state health authorities. For four decades, the Commonwealth's main strategy has been methadone, a drug that blocks withdrawal symptoms and prevents cravings for heroin and other opioids like oxycodone. MassHealth, which cares for about 18,000 low-income opioid addicts, spent $325 million on treatment. Of that, $276 million went to methadone.
But the growing consensus in the medical community is that methadone isn’t always the most effective treatment — and shouldn't be the first choice. Dr. Kevin Hill, a psychiatrist at McLean Hospital's alcohol and drug abuse treatment program, explained new approaches in a Q and A with the Globe's Larry Harmon, who criticized the state’s over-reliance on methadone in his column Sunday.
Larry Harmon: What is the state-of-the art treatment at McLean Hospital for
addiction to heroin and other opioids?
Kevin Hill: In most cases, we recommend buprenorphine (available as Suboxone or Subutex) medication treatment in addition to counseling.
LH: How does buprenorphine differ chemically from methadone?
KH: When someone addicted to opioids takes buprenorphine, they do not feel the full effects, or the "high" of an opioid like heroin or oxycodone. Also, once on buprenorphine, they will not get high from opioids they take. Buprenorphine also prevents them from going into opioid withdrawal or feeling "dope sick." Opioid withdrawal is a miserable experience that often leads to relapse.
LH: Where can people get medications for opioid dependence?
KH: Buprenorphine has fewer side effects than methadone and minimal risk of overdose, which allows it to be prescribed as a treatment for opioid dependence (addiction) from a physician’s office. Methadone used in the treatment of opioid dependence must be given under the careful supervision of a methadone clinic.
LH: Is addiction a mental illness?
KH: Yes, but I find it more helpful to think of addiction as a chronic medical illness, like high blood pressure. Both have a genetic component, a biological basis, and are influenced by both psychological and environmental factors. Many people require both medications and changes in behaviors like diet and exercise to manage their high blood pressure; the same holds true for addiction. Chronic medical illnesses can be treated in order to minimize their impact on the rest of a person’s life.
LH: Do psychiatrists find the treatment of addiction as professionally rewarding as treating mental illnesses such as psychosis and schizophrenia?
KH: Many do. The Commonwealth has many doctors skilled at treating addiction, but we could use many more. Treating patients with addictions is very challenging, but helping someone get back to a productive life as a spouse, parent, or employee is gratifying.
LH: Are there drugs coming on the market that might eliminate cravings and dependence altogether as opposed to providing chemical substitutes?
KH: The majority of patients seek treatment while using, so the goal of many medications is to prevent withdrawal symptoms that can lead to relapse. Buprenorphine and nabilone, a medication we are testing at McLean as a treatment for marijuana dependence, work this way. Once a plan for treating withdrawal with a medication is in place, counseling is used to help patients address the issues in their lives that contributed to their use. The medication is not meant to be a substitute for the drug they were using, but rather a tool to use for a period of time prior to tapering off of the medication when all aspects of a patient’s life are going well.
LH: Are medications alone enough to treat addiction?
KH: No. A patient who thinks that a month’s supply of buprenorphine alone is all they need is unlikely to do well. Counseling is critical. I find that an alliance with the patient — having them feel that you are invested in them getting better — can be the most powerful part of treatment.