Of course with additional treatment responsibilities, a counselor couldn’t be expected to manage a caseload of up to 75.

I’ve noticed a push from some quarters to add therapeutic programming to Medication Assisted Treatment (MAT), particularly Opioid Treatment. That might be a really good idea.

It’s always seemed to me that the Opioid Treatment model was designed to foster overdependence on the medication rather than provide a complete therapeutic experience. That may be part of the reason that retention has been such a problem.

Retention rates vary, but one prominent addictionologist  told me that about 20% of the 700-plus persons he had  enrolled in their hospital-based Suboxone maintenance program were still around. That would be disappointing even if the goal had been six or twelve month of participation. But this program, like most, strongly encouraged clients to stay “indefinitely” (translation: definitely a very long time).

Here’s how the 2015 revised Federal guidelines put it:

“Programs should make every effort to retain patients in treatment as long as it is clinically appropriate, medically necessary, and acceptable to the patient. Maintaining a patient on medication, even when psychosocial treatment or other clinic services may not be yielding optimum results, is beneficial to both the individual patient and the public health. In addition, pharmacotherapy may still benefit patients who no longer need ancillary services.”

Why is retention so important? Because whatever progress has been made appears to come to quick end once the medication stops. Return to heroin or other opioid use can easily exceed 80%, even with an extended taper. Sadly, individual client motivation doesn’t seem to make much difference– the highly motivated struggle, too.

Nonetheless, OTPs aren’t required to provide much in the way of support. The basic Federal requirements:

  • An assessment and plan
  • Quarterly updates during the first year, semi-annually thereafter
  • Counselor to patient ratios per the State– in practice, 1:30 to 1:75.
  • 8 random drug tests a year.

Abstinence from other drugs is not considered a requirement– because, the guidelines say, “even when patients are not fully abstinent from all drugs of abuse, they and their communities continue to benefit from medication-assisted treatment for opioid use disorders.”

The guidelines acknowledge that “alcohol… use is common among patients receiving medication-assisted treatment.” Same for benzos. That’s why it isn’t unusual to encounter an OTP client in Court for a DWI offense.

My thought: why not provide more intensive counseling along the lines of outpatient drug-free treatment? I asked one program director, who said he couldn’t get paid for it. If he could, he admitted, he would. Some of his current clients wouldn’t be interested, but there’d be many who would. The program would have to shift its focus from retention to a more complete form of recovery. But, he conceded, “I think it would make us a better program.”

Why not integrate some of the features of drug-free programs into existing opioid treatment programs? And allow them to bill at current rates for those services? Of course with additional treatment responsibilities, a counselor couldn’t be expected to manage a caseload of up to 75. But that’s fixable.

It’s worth serious consideration. After all, is our ultimate goal to produce patients who are merely “less sick”, or demonstrably “well”?

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