Paving the Way to Sustainable recovery: A Q&A on the Advantages of Outpatient Medication-Assisted Treatment
Dr. James Meacham is a Regional Medical Director at CleanSlate Centers and a stalwart advocate for Medication-Assisted Treatment (MAT). MAT is a groundbreaking, evidence-based approach that combines prescribed medication with counseling and behavioral therapies. MAT has redefined the battle against opioid and alcohol use disorders, providing a beacon of hope to many facing these challenges. This method doesn’t just aim to treat, it seeks to transform—significantly decreasing overdose deaths and helping individuals regain control of their lives.
Beyond individual recovery, MAT impacts our communities by reducing the societal repercussions of addiction, such as illicit drug use and crime. It is a treatment plan tailored to the unique needs of each patient, acknowledging that every addiction story is different, and so is every path to recovery.
To start your recovery journey today
Call (833) 505-4673
What is your experience in addiction treatment and what inspired your interest in it?
Dr. Meacham: I’m an addiction medicine specialist, board certified in addiction medicine as well as internal medicine and pediatrics. I’ve worked at CleanSlate since the fall of 2017. I have previous experience at inpatient treatment facilities and one inpatient treatment facility in particular here in Indiana. Over the years I’ve found myself in the role of Regional Medical director for the state of Indiana, supervising the care in eighteen of our centers in the state.
What got me into this? That’s a much longer story than we can’t get into today. But I’ve known for a long time that helping people with substance use disorders is where I’m supposed to be at this season of my life and here I am.
Did your previous stint in inpatient treatment include MAT?
Dr. Meacham: Yes. If you’re familiar with the ASAM levels of care, inpatient treatment today is primarily medically supervised withdrawal from a variety of substances. Opiates, alcohol, benzodiazepines are the three most common. As time has gone on, accessing that level of care has become a little more difficult, mainly due to the insurance landscape. So yes, I did work with opiate-dependent humans, alcohol-dependent humans and patients who were using benzodiazepines and combinations of those three.
I also helped run an inpatient addiction medicine consult service at a local hospital here in Indiana for two years. Most of our work there was alcohol withdrawal management patients who had come in not for treatment of their alcoholism, but rather for another medical co-morbidity or accident of some sort and then required medically supervised detoxification from chronic alcohol use.
How do you help patients who need to detoxify from opioids or alcohol before receiving medications for opioid or alcohol use disorders?
Dr. Meacham: Patients who are chronically using opiates today often have a hard time accessing inpatient care. It’s hard to say because we haven’t had to admit anybody in a long time. But back when we were battling heroin and shorter acting opiates in the community drug supply, it was increasingly difficult to get people admitted [into detox] because outpatient induction to medication for opioid use disorder was relatively straightforward.
Today with the community-based drug supply being primarily fentanyl and other substances mixed with fentanyl, it’s a little tougher to do inductions in the outpatient setting. But I think we’ve done a good job adapting to that street level drug supply and modifying our induction techniques, so that we can effectively do that in the outpatient setting. I don’t know that it’s better necessarily in the inpatient setting, and certainly I think for a lot of patients it’s even more challenging simply because they don’t feel well by the time they’re ready for discharge from inpatient care. And they’re not being detoxified or withdrawn from opiates to nothing in an outpatient setting. They’re being transitioned from opiates to medications such as buprenorphine, or in some instances long-acting injectable naltrexone [Vivitrol].
Is Naltrexone or Vivitrol used less frequently than medications such as Suboxone?
Dr. Meacham: I think that’s true in general. For opioid dependence it’s challenging to abstain long enough to safely receive your initial injection of long-acting naltrexone.
With medication for alcohol use disorder, do you find there’s any barrier to admit patients, given the need to detox before you can start medication assisted treatment?
Dr. Meacham: No, I think that alcohol use disorder and sedative or hypnotic use disorder are a little different in that the assessment that you do for the dependence that the individual has determines placement and care. For example, it’s not safe to tell some patients who are using alcohol that they should cut back or stop at home. The risk of going into complex alcohol withdrawal in an unsupervised setting is significant in some cases.
The assessment that we do in the outpatient setting determines whether an office-based setting for the management of alcohol use disorder is appropriate, or whether it would be safest to have the patient be admitted to an inpatient facility for medically supervised withdrawal and then return to the outpatient setting for ongoing management. And there are tools that we use to help us make those determinations.
Do the patients who receive medication for either opioid or alcohol use disorder have better long-term outcomes when their treatment also involves behavioral health therapy?
Dr. Meacham: I don’t think there’s any question about that. Medication alone is beneficial, but medication with behavioral health interventions helps people learn about the drivers for substance use, coping strategies, life skills and relapse prevention skills. That improvement comes when patients are engaged with counseling from a chemical dependency therapist and with involvement in some form of community-based 12-step support. I always tell patients that the more resources you utilize in your recovery, the higher the likelihood that you’ll have a sustained recovery from substance use disorders.
Do you find that one of the benefits of outpatient treatment is allowing people to maintain their daily life and responsibilities in a way they can’t when they’re in residential treatment?
Dr. Meacham: Again it’s going back to the ASAM levels of care and selecting the proper level of care for the patient that you’re dealing with. There are patients who really need residential level of care. They have very little coping skills, very poor social determinants of health, poor environment that they’re currently staying in and a low likelihood of being successful in that. With all those things stacked up against them, the chances of success are really low sometimes. It takes a period of stabilization in a residential facility, or sometimes at a lower level of care like partial hospitalization, or even a lower level of care where they can be at home and still attend an intensive outpatient program, for example. I think it’s disingenuous to say that everyone can make it or do well in the outpatient setting. It really depends on the use history, some of the other social determinants of health and where the patient is in terms of their disease.
Many, many patients can do well in the outpatient setting. And when the patient’s appropriate for outpatient treatment, certainly medication for opioid use disorder or medication for alcohol use disorder go a long way to improving those successful outcomes.
Do you think cost is something that speaks in favor of outpatient treatment generally? Granting that inpatient treatment is a necessary starting point in many kinds of cases, is the fact that the average cost of outpatient treatment is typically a fraction of the cost of inpatient treatment a benefit of it?
Dr. Meacham: I think cost is what it is. If a patient needs inpatient detoxification followed by residential level of care, then that’s the cost of their treatment. If they don’t need those things, then certainly outpatient management is a less expensive option.
How does outpatient treatment create individualized treatment plans to address polysubstance use, where, say, a patient has primary opioid addiction and a secondary benzo addiction, or a co-occurring mental health disorder—struggling simultaneously, for example, with alcohol use and bipolar disorders?
Dr. Meacham: The development of each treatment plan is unique to the situation. Referring a patient out to a dual diagnosis facility is sometimes the proper placement for care. But as a rule, many patients can be managed in the outpatient setting with wrap-around behavioral health services, care coordination for housing and other needs, and medication for either opiate or alcohol dependence.
Do you use the language of “harm reduction” when you talk about medications for opioid and alcohol use disorders?
Dr. Meacham: I think “harm reduction” is a term that has taken on a life of its own. It applies to many interventions such as needle exchange programs, continued treatment with medication, and to providing lifesaving naloxone. The way I look at harm reduction in the outpatient treatment setting is more about meeting the patient where they are, doing a thorough assessment of their substance use and their needs, and then trying as best you can to gradually meet those needs over time while retaining the patient in care and stabilizing the most life-threatening components of the disease.
I have very little chance of helping somebody who continues to use fentanyl despite medications I’m prescribing unless I get them to the next level of care. I can work with them for several months; but with continued use, it tells me that what we’re doing is not effective. So finding that next level of care is a form of harm reduction—if you will.
Going back a decade or so, or not even a decade, patients who weren’t completely negative on all urine toxicology were discharged from their treatment program. And many of those patients had very poor outcomes. So some would say that maintaining a patient in care with medication is on some level harm reduction, until they can show improvement—however gradual that may be.
A lot of people throw the term “harm reduction” around and quite honestly, they may have a different view of it than I do. But yes, we do use the term “harm reduction.” And what we do at CleanSlate has a harm reduction aspect to it.
Do you have a general preference for length of treatment or is it purely variable? Do you believe there are some patients whose care requires long-term medication and others who can gradually taper off of it as they progress over time?
Dr. Meacham: That’s the million-dollar question right there. A lot of it depends on the use history. Individuals who have been using high doses of potent opiates for years, and those who have started using at a very early age—perhaps in their teen years prior to some of the maturation of the central nervous system—those may be patients for whom you might consider lifelong therapy.
Most of us who’ve been doing this for a while recognize that a minimum of one to two years while the patient is stabilizing and healing is needed even before you can safely discuss any path away from medication. All along that continuum of care you discuss finding the lowest effective doses of medication so that the patient is—if they choose or desire to be off medication—at some point able to slowly step away from it. It’s very much an individual, patient-centered conversation.
We need to be careful about not stigmatizing the medicine to the point where we say, “you need to be off of this in two years or you need to be off of this in three years.” That’s not what I’m getting at. When I see a patient who’s stable and doing well in treatment, I always ask them “what’s your long- range plan with medication?” And a lot of times patients will say to you, “I haven’t done this well ever. I’ve had 15 overdoses. I’ve been incarcerated three times. I’ve never had a year of sobriety and productive life ever. And I don’t think I ever want to be away from medicine. I don’t think I’ll ever be able to do it.” That says volumes to me.
On the other hand, a patient who might have become dependent on opiates over a shorter period of time and had very little health or social consequences, I ask that question and they say “well, yeah, someday I’d like to be off of medication.” I’ll say, “OK, well, let’s talk about what that might look like and then we begin that journey together.” So I don’t think there’s a one-size-fits-all answer to how long people should be on medicine. I do believe that there are people that benefit from medication perhaps for one or two years. And there are patients who will make attempts at cessation over time and realize that maybe it’s not in their best interest to be off medication. So there’s a broad spectrum there.
Thank you for your time and careful consideration.
Embrace the healing, privacy and continuity of care of outpatient medication-assisted treatment. Begin your journey to recovery today: (833) 505-4673.
