Image: Chinazo Cunningham (General Internal Medicine), Associate Professor and pioneer of the CHCC buprenorphrine treatment program
October 19, 2008 - BRONX, NY - In the south Bronx neighborhood that surrounds the Montefiore Comprehensive Health Care Center (CHCC), street drugs like heroin and crack cocaine are easier bought than a pack of gum. Inside the clinic, however, an innovative buprenophrine treatment program has brought promise for drug users and physicians alike.
Narcotic abuse is rising rapidly throughout the nation, yet fewer than 20% of opioid-dependent Americans are enrolled in substance abuse treatment. Frustrated by the lack of drug treatment options for substance-using patients, Dr. Chinazo Cunningham, a CHCC clinician and Associate Professor of Medicine (General Internal Medicine) at Albert Einstein College of Medicine and Montefiore Medical Center, turned her attention to buprenorphine, FDA approved in 2000 for addiction treatment outside of highly regulated settings. This opioid agonist enables opioid-dependent individuals to stop using drugs without experiencing cravings or withdrawal. Co-formulated with naloxone, an opiate blocker that causes immediate withdrawal if injected, the drug has limited street value, making it safer to provide patients multiple doses. Individuals in the maintenance phase of buprenorphine treatment, (beginning about day eight of treatment), need only visit the clinic every four weeks or so for their supply.
Cunningham and colleagues evaluated potential provider barriers and designed a responsive approach. The result, a clinic-based program offering physician and staff training, ongoing advisement through regular case conferences, and an addiction expert for on-the-spot consultations, was launched in 2004. In the first two years, 41 opioid-dependent patients were treated with a 90-day retention of 71%. Unlike most methadone programs, which often require daily clinic attendance, buprenorphine treatment has the potential to be more patient-centered. Individuals are given “kits” to manage their withdrawal symptoms and initiate buprenorphine treatment, which include detailed instructions, ancillary medications to counter symptoms, and buprenorphine. “Many of our patients have handled their own withdrawal symptoms for years, so they already have expertise,” said Cunningham. “Our approach empowers self-management of their disease.”
Early results are dramatic: in as little as a few weeks, participants improve their health, secure jobs and stable housing, and often reconnect with long-alienated families. “Once their disease is in check, they start to deal with the everyday issues we all face,” Cunningham said. “It’s powerful to see someone’s true spirit emerge after being numbed for decades.”
This population’s inherent transience makes it difficult to account for the 29% who drop out. Incarceration and lack of readiness are two primary reasons, according to Cunningham, who noted that some do return, months later, to try again.
Buprenorphine is neither a methadone replacement nor an opiate addiction cure-all. Patients with severe psychiatric illness or high addiction levels require complex services beyond the program’s capability. “Ideal” candidates are generally regular heroin users who have suffered serious social consequences and are ready to change.
Motivation may talk louder than money in determining a patient’s retention. The CHCC is located in the nation’s poorest congressional district, and most of Cunningham’s patients reflect the clinic’s demographic: 95% are below the poverty line, nearly 20% are uninsured, over 60% are covered by Medicaid. But the buprenorphine program, one of few in the New York City area, has begun to draw individuals from surrounding Manhattan and Westchester, including college students and white-collar workers more likely to abuse prescription narcotics. Despite their resources, these patients have been harder to retain. “Most of my prescription narcotics users haven’t yet lost their family or faced jail time, so they may not see their use as a problem,” said Cunningham. “The heroin users have spent decades living an exhausting, never-ending cycle between the streets and prison. They want to change because they know they have a drug problem, not because their spouse or their boss thinks they do.”
Cunningham, a general internist who has treated thousands of chronically ill individuals, considers heroin users some of her “easier” patients. “Once we overcome the initial hurdles, I’m often left with healthy young people who can live long, productive lives,” she said. “Compared to the complexity of managing asthma or diabetes, it’s pretty smooth sailing.” Even those with HIV infection benefit: with priority refocused from addiction to managing their health, they are more likely to show up for doctor’s appointments and take their medication.
More difficult cases arise when treating a patient’s addiction uncovers a long-suppressed mental illness that requires psychiatric services beyond the capacity of a community health center. Working within the nation’s divided health care system, providers like Cunningham often feel stuck. “I have nobody to send these patients to. I might as well walk up to a crowd and say, ‘Who’s a psychiatrist, takes Medicaid, treats drug users, and speaks Spanish? Raise your hand,’” said Cunningham. “Good luck with that.”
Despite the nation’s rapidly increasing opiate dependence, buprenorphine treatment programs have had a slow start. Patient participation in the CHCC program is increasing—clinic inquiries have tripled in the past year—but physicians remain reluctant, despite the fact that eligibility can be obtained by completing an eight-hour course. “Doctors are scared to treat drug users because our society criminalizes drug abuse, rather than viewing it as a disease,” Cunningham said. “It’s very difficult to abuse buprenorphine, yet many physicians focus on that rather than looking at how often they prescribe powerful narcotics to patients who don’t ‘seem’ like drug users.”
She remains hopeful, though, that the tide is turning, and that her work will pave the way for better access to patient-centered addiction treatment within a supportive, integrated system. “We can really help our patients manage this disease and move forward with their lives,” she said. “It’s exciting—we have a great opportunity to learn how to do this well.”