It is a fact that leaders in any market dictate the language for the market. That’s true in all markets- even in opioid dependence treatment. As one of the founders of Reckitt Benckiser Pharmaceuticals (now Indivior), we took the mantle from methadone treatments for the term Medically Assisted Treatment (MAT) while introducing office based prescribing of Suboxone. Over the last 15 years, the outstanding marketing and branding work done by that team, they have achieved that goal. MAT is now used even by addiction experts to mean prescribing buprenorphine. I was sitting in a meeting recently listening to an addiction expert speak and they kept referring to “MAT with wraparound services.” In my discussions with insurance companies and payers, they equate office prescribing of buprenorphine to being MAT. Yet when we ask them if they have mechanisms in place to ensure that prescribed patients are also receiving behavioral health services, there is invariably no process in place. So at this current time, MAT has come to be used to mean prescribing medications. That was never the intent of this term nor the treatment model.
MAT was a term coined to describe a treatment pathway where behavioral health services traditionally used to treat addicted patients, added medications to help them gain sobriety and enter into recovery. The passing of the OBOT legislation and the efficient manner in which Suboxone grew and developed in partnership with the physician medical associations provided needed relief to patients desperate for care. But as the market accepted the medication, the market shifted. More and more physicians entered the market with a decreasing percentage of them having training or background in addiction. With more physician competition, doctors had less leverage to require patients in their practice to use additional treatment services. If all they wanted was drugs, they could easily find another physician to do so. We now see private equity backed chains of clinics that only prescribe buprenorphine for a cash payment of $150 and a brief visit in the office.
We are at a curious juncture in public health as the greatest public health crisis of our time. The opioid crisis that killed 64,000 people last year and put 2.5 million people in need of treatment is the subject of laws, protocols, recommendations and research, that if practiced would save lives and effectively treat those suffering with addiction. The Surgeon General’s Report of 2016 outlined several evidence based practices representing multiple pathways to recovery for those suffering with opioid addiction. The reality as seen in the chart below is that the overdose epidemic continues to get worse despite the increasing numbers of physicians prescribing buprenorphine, and now over 3 billion milligrams of medication.
The definition of insanity is doing the same thing over and over and expecting a different result. “MAT with wraparound services” has completely failed our patients, communities and our nation. Am I saying that a model of prescribing buprenorphine with behavioral health services hasn’t helped patients? No, it absolutely has…in the beginning. But now with fewer patients seeking counseling and only wanting medications, we have a second public health issue- diverted and abused buprenorphine. Even Indivior, in its initial announcements of its one-month injection of buprenorphine, has positioned Sublocade as the answer to the diversion and abuse of the oral form of the drug. The concern that many treatment experts have around this medication is that many patients will resist any additional services until they need to be reinjected with the medication.
So what is the answer to stopping the continued progression of this opioid epidemic? Real MAT. To achieve that, I led a purchase of a small clinic in the Chicago area and formalized the combination of evidenced based treatment in combination with every approved medication to augment and enhance the behavioral health services. It’s important to understand that the medications quiet the brain, but meaningful change only occurs with the counseling and psychiatric services. As such, the Symetria Method was born.
The Symetria Method uses MAT, which includes both individual and group counseling as well as psychiatric care. What’s lacking in the current version of MAT is the “T”. The “T” in MAT should be emphasized more in the treatment world — it should be front and center, while the patient is also assistedby medication. I would offer a re-branding: Treatment Assisted by Medication, TAM. When this is done properly, Suboxone, Methadone, Naltrexone and Vivitrol are combined with support groups and counseling by one coordinated team in one facility. This treatment approach is simpler for the patient. It makes real time coordination of care possible with a team aligned in its treatment philosophy. The result is that patients are twice as likely to succeed in making it a year without relapse — and at Symetria our patients are succeeding at making a year without relapse four times more than the national average.
Currently there are as many as 22 bills before Congress that address the opioid crisis. These will likely be combined into one act that addresses various parts of the crisis and will go through numerous evolutions as it moves forward through both Houses and finally into Conference. Multiple bills are emphasizing wraparound services that will be enabled through either funding or policy to support patients as they move from treatment to recovery. These wraparound services are simple practical measures such as recovery based housing and job training that give the recovering person a better chance of succeeding by removing obstacles that can be potential relapse triggers or other headwinds. The philosophy is to give the person on the way to recovery an opportunity to not just survive but to thrive. This is smart and represents an evolution in our leaders understanding of the disease of addiction and the rights and dignity of the patient struggling.
What I found in my 20 years in the addiction world is that for many of the individuals dedicating their lives to this mission are influenced by their personal journeys. While that gives them critical insight into the disease and their patients, it also creates a situation where there are many in our field that have been hesitant to embrace new developments in treatment. Even evidence based clinically proven methods. Old school thinking, mythology and religion drives the treatment world with little to no accountability. According to SAMHSA statistics, a 5% success rate persists for abstinence based programs — that means 95% of patients will relapse or die in their first year in traditional abstinence based treatment. Most programs that offer a 28 day in patient residential program as their treatment see patients return after multiple relapses — sometimes to different programs. But the average family puts a loved one in addiction treatment several times before sustained recovery is achieved. I know that was the experience that my family had. Additionally, published studies have shown that for opioid patients in particular, detoxing leads to increased morbidity and mortality by up to 92%.
The three founders from Symetria, Tim Bohman our Chief Operating Officer, Martyn Gibson and myself came from the pharmaceutical industry and the traditional treatment world. We were frustrated that an effective tool like Suboxone, which was proven to save lives, wasn’t being deployed optimally in today’s situation in the US. The lack of coordinated care with medications and behavioral health is preventing patients from entering recovery. More importantly, not all patients respond the same. So one tool in a doctor’s office isn’t the answer. According to this Voxpiece from January, only 2.7% of the 12,000 treatment providers in the nation are offering all of the evidence-based options in the 2016 Surgeon General’s Report on Opioid Addiction. The fact that the CDC, NIH, DOH, SAMHSA, ASAM and the Surgeon General have all agreed and suggested that medication combined with behavioral treatment can reduce death and be a pathway to recovery from opioid addiction is significant and encouraging. Many providers who deliver counseling services have begun to have a physician provide prescriptions to their patients in an attempt to deliver some form of MAT. What has been revealed is that this cobbling together of care providers hasn’t made much of an improvement in patient outcomes. The real impact comes from treatment from a comprehensive program that treats all aspects of the disease by a single team using evidence based methods.
Symetria has a success rate multiple times better than the national average — simply by doing what we already know works as a single comprehensive treatment team and being compassionate and treating opioid addiction like the disease it is. We need to put treatment at the center of it all, using whatever it takes to provide treatment to patients that desperately need it. Using evidence-based protocols saves lives. The drugs aren’t the answer. They are a merely a tool to assist treatment. But leaders in markets dictate language. It’s time for providers to deliver results in patients’ lives and together take the focus off of the medications and onto effective treatment- TAM. Imagine if in the future, the news focused on the number of patients saved rather than the deaths from opioid overdose. It’s time for accountability — in the meantime let’s go save some lives.