Substance Abuse: The Role of Medication in Preventing Relapse

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Drug-related convictions place a substantial burden on the criminal justice system and on society. The MD Magazine Peer Exchange “Medication-Assisted Treatment in Drug Abuse Cases: A Path to Success” features a panel of experts in the criminal justice field who provide insight on medication-assisted re-entry programs.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons, and an associate director of Surgical Intensive Care at New York-Presbyterian Hospital.

The panelists are:

• Phillip Barbour, master trainer with the Center for Health and Justice at Treatment Alternatives for Safe Communities, in Chicago, IL
• Jac Charlier, director for consulting and training, also with the Center for Health and Justice at Treatment Alternatives for Safe Communities, in Chicago, IL
• Jonathan Grand, MSW, LICSW, senior program associate at the Advocates for Human Potential in Sudbury, MA
• Joshua Lee, MD, MSc, associate professor in the Department of Population Health, and a research clinician at Bellevue Hospital Center, NYU Langone Medical Center, and the New York City jails

Peter L. Salgo, MD: We were talking about relapses. You come out of prison, you go back to that same community that you were in. Suddenly, you find yourself with the same temptations, the same sociologic drivers that drive you back to doing it. And it occurred to me looking at the physiology of this, and listening to you, that medication really is critical. So, how important is it? Am I right?

Joshua D. Lee, MD, PhD: Yes. It depends on what disorder you’re talking about. It’s not critical to cocaine addiction. We do not have therapeutic agents that are going to help with that.

Peter L. Salgo, MD: Yes, but we’re talking about opiates.

Joshua D. Lee, MD, PhD: So, opiates, alcohol, and nicotine. And with criminal justice system involvement, you’re typically talking about an opiate addictive population. You just will not get rates of successful recovery or the reduction of recidivism, etc, that you want if you’re not using medications for opiate disorders, or opiate relapse prevention.

Peter L. Salgo, MD: Again, you cannot talk your way out of a receptor-based addiction, is that fair?

Joshua D. Lee, MD, PhD: Yes.

Phillip Barbour: And in my case as well, I was on methadone while I was in the treatment program. I was in a long-term residential treatment program. I wasn’t on it very long. They kept me on it for about 60 days. And, again, I didn’t even know much about the medication. When I was on the street, I actually avoided it, because I thought it was just a form of giving up. I thought, I’m not going to get any better. But, anyway, they put me on methadone. I was on it for about 60 days. It helped me go through the withdrawal. They tapered me off. And then, I had another several months of drug-free living in that facility with regular counseling, group counseling, and individual counseling. When you talk about the people, places, and things, I guess I was smart enough even back then to know if I went back to my home environment where I hung out, that I was probably not going to make it. And that’s actually how I wound up living in Chicago going to a sober living home, and I stayed there for several months.

Again, it depends on the individual. It depends on the counseling staff. They talked to me about those kind of issues, so that I really understood everything that was going on. This wasn’t just about quitting heroin. This was about changing my lifestyle.

Peter L. Salgo, MD: So, you were on methadone for a while.

Phillip Barbour: Yes.

Peter L. Salgo, MD: And then got tapered off.

Phillip Barbour: Yes.

Peter L. Salgo, MD: Now, to put it bluntly, you’re at risk. There’s no methadone on board to blunt the effect of any exogenous narcotic that you may choose to use. You’re on your own.

Phillip Barbour: Sure. But, I was still under control.

Peter L. Salgo, MD: Right. A lot of guys never come off of methadone, and there’s a stigma attached to that. Is that justified? The methadone’s there to be sure that if they choose to use narcotics in a recreational way, it won’t work. Is that fair?

Joshua D. Lee, MD, PhD: Yes, that’s how methadone works. And you’re right though, that there’s a lot of stigma with methadone and going to that crummy clinic, and being handcuffed—as a lot of patients call it—to the clinic. You’ve got to go every day. We use methadone directly through a therapy model in the United States where you have to go to a physical location that is not where you live, present to the window where the nurse gives you a dose, and then you leave. And you do that every day. There’s no other medication treatment or drug treatment really that works that way. You can imagine people get tired of that, and, logistically, it’s burdensome.

So, who would want to do that forever? But, just purely on outcomes, how do people do on long-term methadone, and the chemical itself? How are you, physically, on methadone long-term? It is a long-term chronic treatment that some people need, and should be encouraged to stay on it long term. Most people that are going to get on buprenorphine or methadone, buprenorphine is newer. But, it works similarly to methadone, patients probably prefer, at some point, to get off it. That’s a classic patient perspective.