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A Medical Model to Treat Opioid Addiction—and Link Care
At a time when some 2.2 million people in the United States are addicted to heroin or prescription painkillers and overdoses claim tens of thousands of lives every year, Kenneth Stoller feels the urgency.
As director of the Johns Hopkins Broadway Center for Addiction, he champions a structured yet compassionate approach to opioid use disorder—one that destigmatizes medication-assisted treatment. Last year, the center was cited by the U.S. Office of National Drug Control Policy for its successes. Now Stoller aims to fill in the gaps and help cement patients’ gains nationwide.
Focusing on coordination with community physicians trained to provide buprenorphine in-office, Stoller wants to increase access to the comprehensive, tailored help offered by opioid treatment programs (OTPs) like the Broadway Center.
For two decades, as one of the nation’s 1,400 OTPs, the center has offered adults with opioid use disorder methadone, buprenorphine or naltrexone maintenance therapy. But as The Johns Hopkins Hospital’s ambulatory addiction treatment program, the center focuses more attention on provision of other services, like counseling and housing.
Notably, the center requires addictions counseling and participation in group classes. Only a few sessions may be necessary for stable patients, but more for those struggling with ongoing use. Instilling self-understanding and a hopeful attitude are key to helping clients.
To be sure, Stoller expects many to falter. But he favors a focus on learning opportunities over criticism. “Once people understand what led them to veer off,” he says, “they’re more likely to choose a better track.” He remembers one woman, greatly distraught about her relapse: “I told her she’d had an amazing self-discovery—a ‘good’ relapse. The message was that we believe she can succeed.”
The center’s adherence to counseling tops 60 percent. For most other centers offering psychosocial support, Stoller notes, literature reports around 25 percent adherence.
Still, a major problem surfaces as people seek care—a basic shortage of maintenance therapy. It troubles Stoller that many community physicians licensed to provide buprenorphine choose not to. A Maryland survey, for example, found that only 50 percent of 545 waivered physicians prescribed it. Barriers to treating these patients are well-known. They include poor compliance with care and limited attendance at counseling.
Subtler things are also troubling; it can be hard for doctors not to take patients’ dishonesty personally. “I try to help them understand that it’s a symptom of substance use disorder—just as chest pain is a symptom of heart disease,” he says.
Stoller believes there is great opportunity for OTPs to encourage buprenorphine prescribing by offering physicians support and improving the chance of a positive experience. “We can work through struggles together,” he says. To streamline that help, he’s created a collaborative model he calls Co-OP (Collaborative Opioid Prescribing), which makes OTP expertise available. Patients are concurrently enrolled at the center while receiving buprenorphine from their primary care or psychiatric physician, extending to them the reach of a Johns Hopkins-tested rewards approach to recovery, which includes store gift cards.
Over the years, the Broadway Center’s profile has risen, thanks in part to fate. Just after Stoller took the helm, the program lost some block grant funding. Suddenly forced to promote the program to shore up revenue sources, he began visiting primary care and psychiatric sites. Today, with a deeper understanding of the center’s tactics, he says more M.D.s in the surrounding community are open to using medications and referring patients. Nationwide, interest is growing in replicating the Broadway Center model.
Federal help could be forthcoming: After the government’s drug control policy office singled out the center “as a model for improving the quality of and access to much-needed opioid addiction services,” Stoller was heartened.
Still elusive, however, is a better public opinion of maintenance therapy. Many people consider medically assisted treatment a moral failing or a crutch. Yet, Stoller counters, “If you broke your leg, what would be your best approach—sit on a couch and be immobile or engage in daily life using crutches?”