Advising a person with opioid dependence currently treated with suboxone
September 3, 2013 10:58 AM Subscribe
I am advising a person with ten years opioid dependence currently treated with suboxone. S/he states that s/he wants to get fully clean and sober. Insurance coverage is Medicaid.
What are the options? Is getting "off" suboxone a realistic goal? Is in-patient treatment recommended? Does Medicaid ever cover in-patient?
I have already provided the person with information about the various support groups available and have further advised that they consult with the doctor prescribing suboxone.
What are the options? Is getting "off" suboxone a realistic goal? Is in-patient treatment recommended? Does Medicaid ever cover in-patient?
I have already provided the person with information about the various support groups available and have further advised that they consult with the doctor prescribing suboxone.
Best answer: On the Medicaid question...My understanding is that Medicaid does cover inpatient treatment. I live in Oregon and can talk about how it works here, but this person's benefits administrator/carrier are the ones to ask.
I am assuming from your question that this person is currently clean - meaning they are not actively abusing opiates and/or other drugs. In my area they probably wouldn't qualify for Medicaid covered inpatient care if not wanting to be on prescribed, taken-as-directed Suboxone is the sole purpose of inpatient treatment and if there aren't additional medical, social, cognitive, mental health, or substance abuse impairments that would indicate a medical need/treatment rationale for residential care.
In Oregon this person would have to find and contact inpatient facilities that accept Medicare to determine that s/he meets criteria for inpatient treatment based on an assessment/evaluation. Medicaid authorization is usually built into the assessment process, but YMMV of course. Most places I'm familiar with are pretty good at pre-screening folks and don't make people go through long, invasive assessments if they clearly don't meet criteria.
S/he states that s/he wants to get fully clean and sober.
The person is fully clean and sober if they're not abusing drugs or alcohol. I'd be happy to point you/this person towards some good writing on the subject, but the conceit that folks on opiate replacement medications aren't really clean has a long history in the treatment/recovery community. It's had disastrous consequences for opiate addicts and there is no evidence to support it.
Is getting "off" suboxone a realistic goal?
Depends. You can't advise this person on this question, neither can we. For some it's the right goal at the right time time, for others it's the right goal at the wrong time. For others, being off replacement medication without heaps of suffering may not be realistic.
There are at least 16-20 factors that addiction professionals use to evaluate how appropriate and advisable it is for a patient to taper off an opiate replacement therapy. Combining a detailed, nuanced, compassionate (yet cleared eyed) understanding of the person as an individual with what the evidence says about who is and is not a successful taper candidate is part art, part science. You really want a professional grounded in the research and solid practice experience working with opiate dependence. Most should provide useful medical information and feedback on what's going well and what could use improvement/attention in a person's recovery.
To give an idea of what I mean by "depends"....A good practitioner will look at this person's drug use history - what they used, how they used, how much and for how long. The evaluation should also include review of past treatment attempts, current treatment engagement and the person's history of relapse cycles - if applicable. Their current length of sobriety, stability at their present Suboxone dosage and the severity of withdrawal at lower doses are also important evaluation factors. A professional will also look at the person's relationships, social/occupational functioning and overall physical and mental health. Other factors in an evaluation will include: the person's motivations for staying clean and for wanting to taper off the medication; their level of practice and skill in anticipating, identifying, preempting, and compensating for relapse vulnerabilities/warnings; the strength of their support network and the strength of the person's day-to-day self care (broadly defined). It goes without saying that tapering off medication should be an ongoing collaborative processes between the person and their treatment pros - it should be flexible, fluid, and adaptable to the persons life and evolving circumstances.
So. Yeah. I'd probably advise/refer this person as lightly as possible for treatment/medication information. Their prescriber is the probably the best resource for evaluation and referrals. Next in line would be to get a list of treatment centers that accept Medicaid. Person or you could call and ask them what kind of experience they have with opiate dependence and patients on replacement therapy. Beware of exclusively 12-step based programs and ones that explicitly state that the end goal is always to have the person "clean" from "everything." To be blunt..."off everything" is not appropriate for everyone, the research does not support this and centers that continue to insist on this are not current in available evidence/best practices. Patients pay the price.
Also, you're under no obligation to vet support groups, but do keep in mind that community based recovery groups vary greatly in how hostile/accepting they are towards folks on replacement therapy. Your person might want to go to meetings with a mind to find ones that will support their medication decisions without undue pressure in either direction.
posted by space_cookie at 9:06 PM on September 3, 2013 [2 favorites]
I am assuming from your question that this person is currently clean - meaning they are not actively abusing opiates and/or other drugs. In my area they probably wouldn't qualify for Medicaid covered inpatient care if not wanting to be on prescribed, taken-as-directed Suboxone is the sole purpose of inpatient treatment and if there aren't additional medical, social, cognitive, mental health, or substance abuse impairments that would indicate a medical need/treatment rationale for residential care.
In Oregon this person would have to find and contact inpatient facilities that accept Medicare to determine that s/he meets criteria for inpatient treatment based on an assessment/evaluation. Medicaid authorization is usually built into the assessment process, but YMMV of course. Most places I'm familiar with are pretty good at pre-screening folks and don't make people go through long, invasive assessments if they clearly don't meet criteria.
S/he states that s/he wants to get fully clean and sober.
The person is fully clean and sober if they're not abusing drugs or alcohol. I'd be happy to point you/this person towards some good writing on the subject, but the conceit that folks on opiate replacement medications aren't really clean has a long history in the treatment/recovery community. It's had disastrous consequences for opiate addicts and there is no evidence to support it.
Is getting "off" suboxone a realistic goal?
Depends. You can't advise this person on this question, neither can we. For some it's the right goal at the right time time, for others it's the right goal at the wrong time. For others, being off replacement medication without heaps of suffering may not be realistic.
There are at least 16-20 factors that addiction professionals use to evaluate how appropriate and advisable it is for a patient to taper off an opiate replacement therapy. Combining a detailed, nuanced, compassionate (yet cleared eyed) understanding of the person as an individual with what the evidence says about who is and is not a successful taper candidate is part art, part science. You really want a professional grounded in the research and solid practice experience working with opiate dependence. Most should provide useful medical information and feedback on what's going well and what could use improvement/attention in a person's recovery.
To give an idea of what I mean by "depends"....A good practitioner will look at this person's drug use history - what they used, how they used, how much and for how long. The evaluation should also include review of past treatment attempts, current treatment engagement and the person's history of relapse cycles - if applicable. Their current length of sobriety, stability at their present Suboxone dosage and the severity of withdrawal at lower doses are also important evaluation factors. A professional will also look at the person's relationships, social/occupational functioning and overall physical and mental health. Other factors in an evaluation will include: the person's motivations for staying clean and for wanting to taper off the medication; their level of practice and skill in anticipating, identifying, preempting, and compensating for relapse vulnerabilities/warnings; the strength of their support network and the strength of the person's day-to-day self care (broadly defined). It goes without saying that tapering off medication should be an ongoing collaborative processes between the person and their treatment pros - it should be flexible, fluid, and adaptable to the persons life and evolving circumstances.
So. Yeah. I'd probably advise/refer this person as lightly as possible for treatment/medication information. Their prescriber is the probably the best resource for evaluation and referrals. Next in line would be to get a list of treatment centers that accept Medicaid. Person or you could call and ask them what kind of experience they have with opiate dependence and patients on replacement therapy. Beware of exclusively 12-step based programs and ones that explicitly state that the end goal is always to have the person "clean" from "everything." To be blunt..."off everything" is not appropriate for everyone, the research does not support this and centers that continue to insist on this are not current in available evidence/best practices. Patients pay the price.
Also, you're under no obligation to vet support groups, but do keep in mind that community based recovery groups vary greatly in how hostile/accepting they are towards folks on replacement therapy. Your person might want to go to meetings with a mind to find ones that will support their medication decisions without undue pressure in either direction.
posted by space_cookie at 9:06 PM on September 3, 2013 [2 favorites]
Response by poster: Thank you, space-cookie. Great context, super helpful, really exactly what I needed (but did not know enough to put in exact words).
I would be very pleased to be pointed to (accessible, not too technical, would be best) writing on the subject of recovery and opiate replacements.
posted by ClaudiaCenter at 1:51 PM on September 5, 2013
I would be very pleased to be pointed to (accessible, not too technical, would be best) writing on the subject of recovery and opiate replacements.
posted by ClaudiaCenter at 1:51 PM on September 5, 2013
Best answer: About Methadone and Buprenorphine, from the Drug Policy Alliance. (pdf)
posted by gingerbeer at 9:26 PM on September 5, 2013
posted by gingerbeer at 9:26 PM on September 5, 2013
Also anything by mefi's own maias on The Fix or Time.
posted by gingerbeer at 9:29 PM on September 5, 2013
posted by gingerbeer at 9:29 PM on September 5, 2013
Yup. I was pretty much going to link to maias as well. This one in particular is a good summary of attitude shifts in the recovery/treatment world regarding replacement therapy. Gabor Mate's In The Realm of Hungry Ghosts: Close Encounters with Addiction is an excellent, thorough primer on addiction - it's accessible, well researched and well written. It has some very informative sections on opiate addiction and opiate replacement therapy if you don't have time to wade through the whole thing.
>Here's a decent, but not necessarily expansive, summary of the distinction between drug dependence and drug addiction. The difference is pretty critical to understanding meds like Suboxone and methadone. Patients on opiate replacement therapy are physiologically dependent on their medication to function normally - much like a diabetic is dependent on insulin or a depressed person on an SSRI, but they are no more addicted than I am to my Adderall. I can get by without it, but I do much better with it. The key difference is that addiction globally impairs functioning while medication facilitates it.
Hope this helps. Good Luck!
posted by space_cookie at 11:35 PM on September 5, 2013
>Here's a decent, but not necessarily expansive, summary of the distinction between drug dependence and drug addiction. The difference is pretty critical to understanding meds like Suboxone and methadone. Patients on opiate replacement therapy are physiologically dependent on their medication to function normally - much like a diabetic is dependent on insulin or a depressed person on an SSRI, but they are no more addicted than I am to my Adderall. I can get by without it, but I do much better with it. The key difference is that addiction globally impairs functioning while medication facilitates it.
Hope this helps. Good Luck!
posted by space_cookie at 11:35 PM on September 5, 2013
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posted by gingerbeer at 11:22 AM on September 3, 2013 [1 favorite]