The 2022 American Association for the Treatment of Opioid Dependence, Inc. (AATOD) Conference, the largest gathering ofthe opioid treatment field and the conference oriented specifically toward treatment in opioid treatment programs (OTPs), was held this fall in Baltimore, Maryland. Kenneth Stoller, M.D., director of the Johns Hopkins Broadway Center for Addiction and associate professor in the Johns Hopkins Department of Psychiatry and Behavioral Sciences, served as the chair for the conference. Participants represented all 50 states and some international countries, and work in a wide array of professions and sectors including treatment, recovery services, regulatory/government, social services, law enforcement, accreditation bodies and technology innovation, as well as many others involved in this complex field.
1. What are some of your highlights and impressions from the conference?
This year’s conference theme, “The Power of Collaboration,” absolutely resonated with the participants. We had a wide variety of attendees from all levels of government and professional backgrounds — a range of people who find their work linked in some way to opioid treatment programs and the patients they treat. There are over 1,900 OTPs in the nation. They provide medications for opioid use disorder, including methadone, buprenorphine and naltrexone, in addition to counseling and other recovery support services. But these medical clinics have always been seen as a “black box” to other health care workers and communities. OTPs can operate rather independently, and have therefore gotten marginalized. I think that if OTPs can integrate more meaningfully into the rest of physical medical and mental health care, as well as other aspects of our community, patients will greatly benefit and stigma against substance use disorders will reduce. We succeeded in drawing participants to this conference, and it was great to have a wide community gathering, focusing together on ways to address the opioid overdose crisis.
There were training sessions for those who are just starting out in the field and for those outside the OTP field, as well as for seasoned professionals working to refine their clinical skills, fine tune their programs and implement new and innovative models and services. For the first time, we offered an evening session, titled “OTP Basics for Non-OTP Professionals,” which was open to the general public. We hope to stream this session more widely at the next conference to reach more people who need to understand basics about addiction, the medications OTPs use and other services offered. The conference also facilitated an all-day training for all state opioid treatment authorities, or SOTAs — the government officials who oversee their respective states’ OTPs and buprenorphine prescribers. Such a live training was not possible since before the pandemic, and many SOTAs had found themselves feeling inadequately trained and supported.
Even in the exhibition hall, this year there were noticeably more and new technologies that are being made available in this field. Medical devices and mobile apps are increasingly developed and utilized to complement medical and counseling services offered in treatment programs.
The two hot topic areas this year reflected in the variety of workshops and plenaries offered were: 1) making medication-assisted treatment accessible in correctional facilities and other justice settings and 2) expanding methadone access in rural areas that currently do not have OTPs. Regarding the latter, mobile methadone vans are now permitted to expand the access radius of OTPs, and one manufacturer of such vehicles parked a van at the conference for attendees to examine — complete with a dispensary, exam room and waiting area.
2. Let’s dive into the issue of increasing methadone access in rural areas …
There is a proposal to widely allow physicians to write prescriptions for methadone to be filled in community pharmacies. AATOD opposes this approach, given a past history of methadone-related overdoses when prescribed in this manner for pain. The decades of experience OTPs have had demonstrate that especially early in treatment, patients need careful monitoring and support to safely and effectively recover. Most office-based practices cannot provide these supports or frequent dosing monitoring, and sending a less-than-stable patient home from the pharmacy with a bottleful of methadone can lead to the patient taking it not as prescribed or diverting/selling it to others. Additionally, the support, encouragement and services available to patients in the OTP site would not be available, and therefore, patients who need more than medication would not have at their fingertips what they need to build a strong and meaningful recovery. I am very much in favor of research that evaluates methadone pharmacy prescribing, starting with more stable populations, but the field should not jump way out ahead of the evidence.
“Medication saves lives, but comprehensive treatment rebuilds lives.” We’d like to steer the discussions away from stop-gap, short-sighted solutions and, rather, focus on access AND quality AND safety, shifting our efforts from simply expanding treatment access to expanding access to comprehensive treatment. As an example, if excessive OTP regulations and accreditation standards were revised and simplified, it would facilitate the opening of small OTPs in rural areas, whereas in the overregulated current environment, OTPs treating fewer than 100 patients have to spend too many resources just to demonstrate adherence to all administrative requirements. Additionally, by leveraging telehealth, mobile vans and fixed satellite sites, given regulatory flexibilities being established, the footprint of comprehensive OTPs in cities or suburban areas can be increased.
3. One of the conference objectives is “To address and refute misinformation and stigma and promote acceptance of comprehensive medication-assisted treatment (MAT) throughout the continuum of care.” How has the acceptance of MAT changed, if at all, in the medical community at large? What is usually the tipping point for a medical professional or organization to accept and advocate for MAT?
The usual experience of our medical colleagues with persons with opioid use disorder is in the emergency room or acute hospital wards — when they usually see them at their worst, during a time when they are not in control and often intoxicated, withdrawing, in distress and demoralized. Education in substance use disorders and recovery-based approaches to SUD treatment, including being exposed to positive experiences with treating addicted patients, or interacting with individuals who are stable in recovery, are key.
At The Johns Hopkins University, second-year medical school students spend time learning how to take an SUD history and practice interacting with patients with SUD in small group discussions with patients at our Broadway Center for Addiction. This practical experience is one of the most highly rated elements of their SUD training — hearing our patients’ stories is transformative to many students. There’s usually a lot of shared tears shed as patients and students emerge from their small group discussions. Social worker and assistant professor Dan Buccino, clinical manager of the Broadway Center, has been working with me and the U.S. Substance Abuse and Mental Health Services Administration to improve social work school curricula on SUD, by creating a learning collaborative that has been in place for quite a few years. Many have been quite successful in developing a much more robust, evidence-based and recovery-oriented curriculum for their students.
Integrative models have also been critical. In 2009, our program developed the first buprenorphine hub-and-spoke model, through which patients were started on medications and counseling in our program and, when stable, transitioned buprenorphine provision to their office-based physicians. Before that, local medical providers were concerned about complexities and difficulties they perceived comes with providing buprenorphine treatment. By having our comprehensive OTP take over the most difficult elements of treatment, including resumption of medication provision for patients who destabilize while receiving buprenorphine prescriptions by their physician, these community providers gained a positive experience of working with this population and became less reluctant to provide treatment.
4. What makes you hopeful for the OPT field?
My hope is derived from seeing our patients get better, rebuild their lives and get back into their communities. I am moralized by seeing families reunited as a result. I get encouraged every time an ex-patient stops me on the street to tell me how well they are doing. As a society, we need to understand that opioid use disorder is a complex and complicated disorder, and that it’s not one “simple” condition, but rather, the result of a set of factors — biological, behavioral and societal. Comprehensive components include addiction pharmacotherapy, mental health assessment and treatment, addressing physical health, pain management, stable housing, developing coping skills, spirituality, accountability, harm reduction, enhancing social supports, productive and recreational activities, addressing stigma and so much more. OTPs that offer comprehensive services, whether directly/integrated or through facilitating referrals and motivating those linkages, help patients get better, build or rebuild satisfying lives in recovery, and get back to functioning in their communities.