Researcher Asks Why Some Abandon Treatment for Prescription Opioid Addiction

By Spencer Watson

“Only about 18 percent of people who need medication-assisted treatment for opioid use disorder actually get it. Why? Why aren’t people using this treatment if it’s there and we know it works? Why are people, once they are in treatment, not successful in staying in treatment or successful after treatment?” she asked. “This is what I’m interested in. We really need to better understand what the decision factors are for people to enter treatment, stay in treatment, and stay in recovery.”

Wright saw an opportunity to collaborate with researchers Alison Oliveto, Ph.D., and Mike Mancino, M.D., in the UAMS Psychiatric Research Institute who are leading an on-going study of medication-assisted treatments for opioids in a randomized controlled trial.

She received funding in September from the National Institutes of Health for two years that is allowing her to conduct in-depth interviews with those study participants at key decision points in the treatment process. Her goal is to determine critical attitudes, barriers, facilitators and preferences among persons with prescription opioid use disorder that impact seeking, entering and sustaining treatment to stop opioid use and prevent relapse, as well as get their input into the effectiveness of the treatment itself.

“After patients come in and stabilize, I tend to start at the beginning with asking them about their first experience with prescription opioids; I then ask them to continue with their story up to the present day. How did you decide to come into treatment right now? What was going on in your life? In your mind? What were the things that brought you here? Was there a tipping point or some crisis factor? Was it a gradual decision made over time?”

Every story is unique in these interviews, which are conducted after detoxification upon entry into treatment, at three weeks and finally at 16 weeks to follow up. However, Wright said some patients do have things in common, and those can be used to help inform approaches to treatment and policy as health care providers and policy makers work to tackle the national opioid epidemic.

“One of the things I’m finding out is that it’s like a well-kept secret,” said Wright, pointing specifically to treatments like buprenorphine, a medicine that relieves withdrawal symptoms, and naltrexone, a medicine that curbs opioid craving without the high. “Some of the drug users that I’m interviewing aren’t even aware of the medications. I mean, everybody’s heard of methadone, but they haven’t heard there are other things they can take. They haven’t heard there’s a program they can get into. They don’t know where to go or who offers it.”

Still, even knowing sometimes isn’t enough, Wright emphasized. Doctors or APRNs are required to have a specific certification to prescribe buprenorphine, and while that certification is not difficult to get, Wright said, there are few providers in the state who have it.

In fact, Wright said some of the patients she’s interviewed have told her they’ve even been actively discouraged from pursuing medication-assisted treatment by health care providers who believe true sobriety excludes taking medications to combat addiction. They see such medications as swapping one addiction for another.

“There’s still a lot of education that needs to happen there,” she said. “Some providers are reluctant to deal with these issues. They don’t want to have to talk to their patients about addiction or to confront them about it. Those kinds of personal behavioral issues are something that some providers are just not comfortable with. So the questions aren’t asked, the problems aren’t dealt with, and here we are.”

As for patients, Wright said one thing that often shows up in those who abandon treatment is that, for them, drug abuse has been normalized. A patient may have grown up seeing parents or other adults use for many years, and thus slipped into abuse themselves. Likewise, using from a young age and continuing for many years makes life without drugs almost an alien idea.

“It can be pretty scary to quit, because it’s not just a matter of saying you’re not going to take drugs anymore,” Wright said. “It’s a matter of figuring out a whole new identity and lifestyle.”

Wright has found that in the clinical trial she’s working with, many patients struggle to take the step from the daily medication buprenorphine to a long-term, once-a-month medication called naltrexone. The way the program is designed, naltrexone is given on a Monday because it only works when the body is free of opioids. But many patients, after taking buprenorphine on their last Friday, will relapse over the weekend and thus can’t take the naltrexone injection on Monday.

“Some patients have suggested, when I ask, that if this transition took place during the week, they’d at least have a counselor they could call and it would be easier,” she said. “So, moving forward with program design, that’s something to really take into account.”

It’s those kinds of insights that she hopes will guide development of more effective outreach and treatment strategies to benefit public policy when her research is complete. Meanwhile, she intends to keep asking questions in the hope of finding better ways to help more people struggling with opioid addiction get into treatment, stay in treatment and stop using opioids.

“I had a study participant once who told me she knew she was considered ‘nothing but a crackhead.’ At one point she said, ‘You know I used to be somebody. I used to be a real person.’ There’s still awareness there, when addicts don’t even feel like a human being anymore. And all too often that’s how society treats them, like they’re not even human.”