Abstract
The current opioid epidemic afflicting the US is not a uniquely American phenomenon. London, like every other global city, is home to thousands of high-risk drug users. I am a psychiatrist currently based in Massachusetts. This time last year, I was working as a psychiatrist in a National Health Service Drug and Alcohol Community Clinic in central London where I was a member of a busy multidisciplinary team. Working with me were nurse practitioners, pharmacist prescribers, social workers, community psychiatric nurses, other physicians, voluntary sector support workers and people with lived experience. There was also a needle exchange on site.
On the first day of my placement with this team, I was given a handful of protocols about opioid and alcohol detoxification regimens and told not to deviate from them. It turns out that addiction, perhaps more than other areas of mental health, lends itself to a protocol-driven approach. It is here where the similarity between the opioid epidemic of the US and England diverges.
The evidence base is clear about what works – and what doesn’t – for this population, best summarised in the 2007 National Institute for Clinical Excellence Guidelines.
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These recommendations are clear-cut that ‘staff should routinely offer a community-based program to all service users considering opioid detoxification’. A few exceptions to this community-based model of care exist, as follows:
People who have not benefited from previous formal community-based detoxification. People needing medical and/or nursing care because of significant co-morbid physical or mental health problems. People requiring complex polydrug detoxification, such as concurrent detoxification from alcohol or benzodiazepines. People experiencing social problems that will limit the benefit of community-based detoxification.
During my time at the community clinic in London, I treated hundreds of people with drug and alcohol problems. Some people attended scheduled appointments but most were walk-ins. I referred less than a handful of these patients for inpatient detoxifications. The population is not any less complex than those seeking help across the US today. In fact, complexity was the norm.
Community-based opioid detoxification works. In England, we routinely track a range of outcomes in a national database including knowing whether people completed treatment and whether they re-presented to services on a rolling 12-month basis. Time in treatment is also monitored, often in years rather than months and weeks. Other metrics include: waiting time; housing status; and number of days working/in employment.
The UK’s community-based model for detoxification is mirrored in Australia’s 2014 National Drug Strategy. So why, amid growing numbers of people addicted to opioids, has the US healthcare system lagged in adopting the evidence base for a community-based model of care for this population?
With the lens of working in the US health system for nearly a year, it’s evident that there are ideological barriers to overcome regarding the role of medication-assisted treatments for people with opioid use disorder. Until such stigma is overcome by the science, inpatient detoxifications – an outdated model of care delivery – will predominate.
Despite US population-based studies showing the efficacy of MAT, many policymakers, and indeed providers, remain stubbornly ambivalent about this approach. Recent data from Clark et. al. 2 demonstrate unequivocally that opioid agonist therapy with either methadone or buprenorphine reduces the risk of relapse by approximately 50% compared to behavioural treatment without opioid agonists. 2
Evidence-based community models of care for people with opioid use disorder are growing but not as fast and with as much priority as the circular discussion about needing more ‘inpatient beds’. Frankly, the relapsing and remitting nature of these conditions mean that we will never have enough inpatient beds for people with opioid use disorder. Instead, we need to go where the evidence takes us: a community-based model of care.