Aerial view of St Louis Missouri, with the Old County Courthouse centered.

Medication First: Working In Missouri, Despite Stigma

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For the first time since 1990, the U.S. experienced a drop in drug overdoses in 2018—a modest 4-5% compared to 2017.

Opioids remain the leading cause of overdose death (70% of the 68,000 total in 2018). But a lower rate of overdoses is something to celebrate. Addiction researchers and other leaders are warning that we shouldn’t scale back efforts to increase access to prevention, treatment, and recovery services for people with opioid use disorder (OUD). Instead, this reduction should be a signal to redouble our efforts.

Federal grants administered through the Substance Abuse and Mental Health Services Administration (SAMHSA) support the current efforts to increase access to services. These grants total more than $3 billion to all 50 states, the District of Columbia, and U.S. territories. The program was first called Opioid State Targeted Response (STR), and now State Opioid Response (SOR). With it, states use a significant proportion of the grant funds to expand access to medications for OUD (MOUD), especially buprenorphine-naloxone (brand name Suboxone®). Buprenorphine is a partial opioid agonist. It has a safer profile and fewer regulatory requirements than methadone. It also has an easier induction (and thus greater overall efficacy) than injectable naltrexone (brand name Vivitrol®).

Missouri’s strategy for addressing the opioid crisis was expanding access to buprenorphine. They did this by developing the ‘Medication First’ approach to treating opioid use disorder. Working with the publicly-funded SUD treatment system, researchers and state officials with the Department of Mental Health developed a set of four principles meant to guide clinicians who were unfamiliar with best practices for buprenorphine prescribing.

These four principles are:

(1) Clients receive pharmacotherapy as quickly as possible, prior to lengthy assessments or treatment planning sessions;

(2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits;

(3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy;

(4) Pharmacotherapy is discontinued only if it appears to be worsening the client’s condition.

These principles were developed in the context of a traditional SUD treatment system that often relies heavily on group therapy, psychosocial services, and 12-step-based models of care. These modalities can be helpful for many, but so far research consistently points to buprenorphine being superior in its ability to retain people in treatment and save lives. Indeed, many people do just as well in their recovery with buprenorphine alone as with additional psychosocial services. The Med First approach advises using psychosocial services as appropriate, but not as a ‘stick’ to get to the ‘carrot’ of buprenorphine (principle #3 above).

What are the results?

Recently published results from the first year of implementation show evidence of progress (see references below). Compared to the year prior to implementation, patients were more likely to receive a prescription for buprenorphine—and much sooner, which is crucial to stave off withdrawal symptoms. And they were more likely to remain in treatment at 1, 3, 6, and 9 months.

“The most commonly given reason for negative attitudes is that “buprenorphine is an opioid” and thus has the potential—however low—to be “abused.””

However, despite these efforts, Missouri is an exception to the progress made nationally in decreasing opioid overdoses; rather, the state saw a 17% increase compared to 2017. Many of these deaths are driven by the St. Louis region, where the city saw a 50% increase in Black male opioid overdose deaths. This raises critical questions about the effects of institutional racism and how it could be impacting Black people’s access to treatment and the life-saving opioid overdose reversal drug, naloxone.

Moreover, we do not yet have evidence of system-wide increases in buprenorphine prescribing outside of patients who are uninsured and thus receiving their medications through SOR funds. If these federal dollars were lost, it could jeopardize our progress. Missouri has not expanded Medicaid, and currently eligibility requirements are among the strictest in the nation.

The stigma toward medically assisted treatment is damaging.

Finally, though certainly not unique to Missouri, there is pervasive stigma toward medications for OUD, including buprenorphine, but especially methadone. Injectable naltrexone is more acceptable, despite its inferior outcomes. These beliefs are found among people with OUD, their family members, mutual aid and recovery services programs, and behavioral health and medical providers.

“However, as with all things addiction-related, the reality of buprenorphine stigma is likely more complex and has its roots in the black market for buprenorphine.”

The most commonly given reason for negative attitudes is that “buprenorphine is an opioid” and thus has the potential—however low—to be “abused.” (In reality, buprenorphine is a partial opioid agonist. It is most often prescribed as Suboxone®, which is formulated with the opioid antagonist naloxone, thus making it even harder to misuse.)

However, as with all things addiction-related, the reality of buprenorphine stigma is likely more complex. It has its roots in the black market for buprenorphine (people who have been prescribed buprenorphine giving it to friends or selling or trading it for illicit drugs). While the conclusion could be that buprenorphine’s stigma comes from this illicit ‘aura,’ the discomfort goes deeper than that. Many people associate buprenorphine with doctors who really don’t care and patients who really aren’t trying. They think these patients don’t “really” want to get better, or else they would learn to manage cravings on their own (use for withdrawal is more acceptable). When people complain doctors are prescribing Suboxone too freely, what they are saying is: “They are prescribing it to too many people who are not willing to work hard enough to change themselves, and that’s the only kind of change that matters.”

Fighting the myth of self-sufficiency.

Why does this internally-driven change matter so much? It comes up again and again in conversations and qualitative data collection, and does not appear to be limited to addiction. Indeed, people with OUD are as resistant as others with chronic conditions to being on medications for the “rest of their lives.” This reminds us that addiction is not an exception; it is only the stigma of addiction that is so exceptional.

“People with OUD are as resistant as others with chronic conditions to being on medications for the “rest of their lives.” This reminds us that addiction is not an exception; it is only the stigma of addiction that is so exceptional.”

Buprenorphine stigma isn’t really about whether someone can get high on it. The resistance really seems to be rooted in a more interesting, complex, and challenging question about what it means to be reliant on anything—heroin, buprenorphine, antidepressants, or insulin—to do what we have convinced ourselves we should be able to do on our own, independently. What do we—as people, with or without addiction—think dependence (or even perceived dependence) says about our internal resources? About our strength as a person, our willpower, our ability to fundamentally change? There is a kernel of truth, after all, to the idea that “you have to want it.”

Most meaningful behavior change requires some reckoning with the self: Is the behavior I’m engaging in detrimental enough to who I am, and who I want to be, that I must change it—or else? Often, the stigma and negative consequences associated with addiction have made the “or else” too frightening to contemplate. Are people with OUD perceived as somehow robbed of that reckoning if they take buprenorphine to manage cravings, sometimes for years or decades?

“We consistently hear that a critical part of recovery is the person with addiction knowing there is someone who cares about them. If they also knew that person was willing to talk through what it means to confront the self, the rapport—and thus recovery—might grow even stronger. ”

Moving past our assumptions and discomfort.

Behavioral health care providers are not immune to these uncomfortable questions. They might harbor their own doubts about the value of buprenorphine in recovery. Or they may worry that their value as counselors is being usurped by a mere pill. But qualified behavioral health care providers are well-suited to work with clients through these existential questions. They can help patients examine what it means to have control over one’s own mind and self, or to be “dependent” on a medication. We consistently hear that a critical part of recovery is the person with addiction knowing there is someone who cares about them. If they also knew that person was willing to talk through what it means to confront the self, the rapport—and thus recovery—might grow even stronger.

As we continue to expand access to evidence-based treatments such as buprenorphine, there will be a limit to how much buprenorphine can help if we do not start to address these questions more directly. We all need to explore the questions at the basis of the apparent divide in the treatment and recovery world.


References:
Larochelle, M. R., Bernson, D., Land, T., Stopka, T. J., Wang, N., Xuan, Z., … Walley, A. Y. (2018). Medication for opioid use disorder after nonfatal opioid overdose and association With mortality. Annals of Internal Medicine, 169(3), 137. https://doi.org/10.7326/M17-3107
Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2014). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews, (2), CD002207. https://doi.org/10.1002/14651858.CD002207.pub4
Winograd, R. P., Presnall, N., Stringfellow, E., Wood, C., Horn, P., Duello, A., … Rudder, T. (2019). The case for a medication first approach to the treatment of opioid use disorder. The American Journal of Drug and Alcohol Abuse, 45(4), 333–340. https://doi.org/10.1080/00952990.2019.1605372
Winograd, R. P., Wood, C. A., Stringfellow, E. J., Presnall, N., Duello, A., Horn, P., & Rudder, T. (2019). Implementation and evaluation of Missouri’s Medication First treatment approach for opioid use disorder in publicly-funded substance use treatment programs. Journal of Substance Abuse Treatment. https://doi.org/10.1016/j.jsat.2019.06.015

Erin Stringfellow, MSW, PhD is an Assistant Research Professor at the Missouri Institute of Mental Health, University of Missouri, St. Louis. She works with a dedicated, passionate team to conduct evaluation and research of federally-funded opioid-related grants. She specializes in applying qualitative and systems science methods to improving outcomes for people living with addictions. Her goal is to engage communities to develop sustainable interventions and policies that support recovery from addiction.

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