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Battling the Opioid Epidemic

In this article published in the spring 2018 edition of Today's Christian Doctor, Dr. Stephen Manchester outlines how you can integrate spiritual care into opioid treatment in your practice. Plus, for the first time in the magazine's history, you can earn continuing education credit with this article. 

by Stephen L. Manchester, MD, FAAFP

As I walked through the park, I heard a man call out my name, “Dr. Manchester!” I looked to see who was speaking, and as he approached he asked, “Do you remember me?”

He did not look familiar so I responded, “Can you jog my memory?”

“You treated me for my heroin addiction,” he said. The man then pointed to his wife a few feet away, whom I had also treated. As we spent some time talking, it became obvious they had gained weight during their recovery and looked considerably healthier, which accounted for why I hadn’t recognized them. While they were quite thankful for the medical treatment I had given, the thing they wanted to talk about was their spiritual journey.


My family and I had returned to the United States for a year of Home Ministry Assignment. As a healthcare missionary, finding a temporary workplace that was going to help me catch up on current practices in family medicine was a high priority. I needed to gain more experience and learn the newest treatments, medications and more. The problems facing patients in our small Ohio community were vastly different from the problems I faced on a daily basis while treating patients at Tenwek Hospital in Kenya.

I just didn’t realize how different they had become.

For the first few weeks after we returned to our home base in Ohio, the local newspaper ran articles on the front page nearly every day about the same subject: opioid addiction. So when I contacted the local community health center where I had previously worked to see if they had any openings, it was not surprising that treating opioid addicts was their urgent, pressing need.

They invited me to talk to the behavioral health clinician about the ramping up of a Medication Assisted Treatment (MAT) clinic they had started using Vivitrol. I wasn’t certain what Vivitrol was; in fact, I didn’t even know that MAT meant helping addicts in their recovery. It turns out Vivitrol is an extended-release naltrexone injection (XR-NTX) that is used to block the effects of opiates and keep those seeking recovery protected while they pursue their behavioral therapies. According to R.L. Wynn with Wolters Kluwer, “This extended-release opioid antagonist is particularly appealing to patients and providers who are unlikely to access opioid-agonist maintenance treatment such as methadone therapy, or methadone-buprenorphine (Suboxone) therapy and who prefer a relapse-prevention medication.”

This gave me pause. After all, I’d been serving in rural Kenya, and I had no recent experience in addition medicine. Nevertheless, the continual bad news coming from my community stirred up compassion in me, not unlike that I felt for my Kenyan patients, and compelled me to participate.

My plan was simple. I was going to continue using the same holistic approach that had become my routine while working at Tenwek for the last 12 years. My goal was to bring healing by addressing each person’s physical, emotional and spiritual brokenness. The old metaphor of a three-legged stool came to mind: if any of the legs are broken, the stool falls over. I just wasn’t sure if this population of patients was open to a spiritual component in their treatment.

My very first patient at the clinic offered me the opportunity to put my plan into practice. After the physical and emotional issues were taken care of, I introduced the need to discuss spiritual care and asked if I could read from the Bible. My patient consented. As I read from Romans 8 about how nothing can separate us from the love of God, I wasn’t sure what response to expect. The patient hesitated, but then she launched into a detailed but important spiritual history, told with great emotion. At the end of the visit, I asked if I could pray with her and she agreed. As she left the room, she was happy to have a plan for her recovery and remarked that she couldn’t wait to tell her mother that for the first time ever a doctor had prayed with her. That encounter was just the beginning. With rare exception, this pattern repeated itself with each subsequent patient.

Because I understood my patients would be in the fight of their lives, I wanted to know the predictors of successful long-term abstinence. As I searched the literature, I was overwhelmed with references to spiritual wellness including, but not limited to, 12-step programs. Several studies cite the importance of spirituality in addiction recovery. In one study from Alcoholism Treatment Quarterly, the researchers found “that recovering individuals have statistically greater levels of faith and spirituality than those continuing to relapse; also that relapsing individuals show significantly lower levels of spirituality than those in recovery.” Another researcher went on to say that the faith journey in recovery “is often an intense spiritual journey that leads to sustained abstinence.” A study that looked at the attitudes toward a holistic approach for inner city substance-dependent HIV patients found that a large majority of those studied expressed a high interest in receiving spirituality-focused treatment. Incorporating spirituality into treatment is not only beneficial, but those seeking treatment are pleased when clinicians and counselors integrate it into their care.

Armed with this reassurance, I continued. Second-visit patients were read to from Joshua 1:9, “...Be strong and courageous...for the Lord your God is with you wherever you go” (ESV). Other readings proved to be powerful and comforting, evoking an emotional connection between my patients and God (Isaiah 40:28-31, Matthew 11:28- 30 and Psalm 23). The goal of these conversations was to assure these children of God that love and mercy, rather than condemnation and shame, come from Him unconditionally. I ended each visit with a prayer and a recommendation of a church or meeting that celebrated and encouraged recovery.

Our team found that by getting to the third consecutive monthly XR-NTX injection, patients were much more likely to continue with the behavioral therapy in the long-term, since they were protected from the effects of opiates. Because of this, we celebrated the third injection with a certificate, a card of congratulations and a small gift card. Such encouraging interactions are rare for those struggling with addiction, so this un-manipulated, unexpected recognition of their achievement was extremely powerful.


CLINICAL CONVERSATIONS

One of the great challenges in using XR-NTX is that the patient needs to be free of opioids before initiating treatment. This requires seven to 10 days of abstinence from heroin or oral prescription opiates, as well as up to two weeks or more abstaining from oral buprenorphine. During this time of withdrawal, we used supportive medications. Zofran can be given for nausea, loperamide for diarrhea, an NSAID for pain, doxepin or quetiapine for sleep and clonidine to mitigate the autonomic response. But the symptom concerning my addicted patients most was muscle aches. For this, they can be prescribed 300 mg of gabapentin three times a day for up to two weeks. If a longer time is needed, then a follow-up visit is necessary. The use of gabapentin is somewhat controversial since it has a street value of its own, but in a model of risk reduction, a short, low-dose course was beneficial and certainly increased the likelihood of a successful withdrawal.

Some patients need more help than this, and a few options remain. For most of our difficult cases, we employed a course of oral naltrexone. Oral naltrexone comes only in a 50 mg tablet. Giving 50 mg or even 25 mg will induce an immediate precipitated withdrawal, which can result in significant morbidity. Titrating up from a very low dose, however, brings the patient through a rapid but controlled withdrawal while, at the same time, starting to block them from the effects of opiates should they relapse. In order to provide this, we found a compounding pharmacy to make and package each dose. The resulting titration pack started with a dose of 0.25 mg the first day and increased up to 25 mg by the eighth day. Patients found this to be very helpful because it put a clear timeframe on their withdrawal.

On the day of the first dose of XR-NTX, we evaluated the patient’s completion of the withdrawal period. Upon exam the patient had to demonstrate the lack of evidence of autonomic overdrive or intoxication. A urine specimen must be negative for opiates and meet the criteria of a true urine specimen. Observing the patient during the production of the specimen is recommended, despite the resistance from the patients and staff. If satisfied that the patient is opiate-free, the physician should administer an oral naltrexone challenge. If no evidence of withdrawal takes place in 30 to 60 minutes, the first XR-NTX dose can be given. The patient should remain in the exam room for an additional 30 minutes before release. And for the next 30 days, they will feel no effect from the use of opiates.

In the first few months, we found that occasional patients somehow sensed the falling levels of naltrexone in the week before their next dose. This resulted in significant anxiety and made some patients think MAT wasn’t working. Whether the effectiveness was really waning is not clear, but the problem was easily remedied. We warned patients of this side effect and offered to call in a prescription for oral naltrexone to augment their levels when needed. Naltrexone 50 mg daily for the week prior to the next injection always mitigated the effect and was usually only needed in the first three months, if at all.

To avoid hepatic-related adverse events, patients need to have a minimally healthy liver. So on the first visit, we obtained a complete metabolic panel with liver enzymes, CBC, Hepatitis B and Hepatitis C tests. As long as the liver enzymes were less than eight times elevated above the upper limit of normal, they were acceptable candidates for XR-NTX. In most cases of elevated liver enzymes, they would return to normal with abstinence from opioids. In general, all heroin users will be positive for Hepatitis C, so a test that reflexes to viral load and genotype should be used. Treatment of their hepatitis can wait until they have been abstinent for six months.


SPIRITUAL CONVERSATIONS

The next step in our process was to discuss spiritual wholeness. Major themes that emerged during patient encounters were guilt, shame and broken relationships. These issues need to be addressed openly. For substance abusers, their addiction takes away everything they hold dear, thus many destroyed relationships result in painful emotions. That is why I started with Romans 8, because it assures them of God’s unconditional love. “For I am sure that neither death nor life, nor angels nor rulers, nor things present nor things to come, nor powers, nor height nor depth, nor anything else in all creation, will be able to separate us from the love of God in Christ Jesus our Lord” (Romans 8:38-39, ESV). Unlike in their human relationships, God doesn’t fall victim to their constant attempts at deceiving, manipulating and stealing. He will never stop loving us! These verses are such a powerful reminder for patients struggling with the damage they have caused.

Women fighting addiction have a special measure of shame since most have used their bodies at some point to obtain drugs. Ann Voskamp wrote a passage about the woman caught in adultery that speaks to this issue, so I shared it with them. Because biblical literacy was typically low with our patients, I prefaced the reading with a brief retelling of the story from John 8:1-11. In The Broken Way, Voskamp says:

...Jesus kneeling down in front of a woman caught in adultery, and it comes like a slow grace, how Jesus handled her critics: He deeply unsettled the comfortable and deeply comforted the unsettled. The woman grabbed by the Pharisees was given what I myself desperately need. Before all the pointing fingers, Jesus looked up at the wounded and rewrote her fate: “You’re guilty but not condemned. You’re busted up, but believed in. You’re broken, but beloved.” 

Whatever you’re in caught in, I make you free. Whatever you’re accused of, I hand you pardon. Whatever you’re judged of, I give you release. Whatever binds you, I have broken. All sin and shame and guilt and lack I have made into beauty and abundance. 

Who gets over a love like this? In the midst of trials, Jesus guarantees the best trial outcome: you’re guilty but you get no condemnation. No condemnation for failing everyone, no condemnation for not doing everything, no condemnation for messing up every day. Who gets over a release like this? 

The Bible speaks to the concerns of men as well. One such passage is of David’s sin with Bathsheba in 2 Samuel 11. After briefly explaining the story, reading David’s confession and prayer for forgiveness in Psalm 51 gave great encouragement to these men. Many of our male patients came from residential treatment facilities accompanied by their recovery counselors, who are themselves often recovering addicts. At one such visit when I shared this passage with the patient, I was surprised when the counselor spoke up and said, “Thank you, Doctor, that was just what I needed to hear!”

After realizing that few of my patients owned Bibles, I started offering them the Recovery Bible or the Celebrate Recovery Bible so they could follow the included devotional plans. It wasn’t long before word got around in the addiction community that I was a spiritual resource, and patients occasionally asked for a Bible before I had a chance to offer them one. Not all, but most of the patients I encountered were interested in God’s forgiveness, His grace and His mercy.

Praying for patients has therapeutic benefit as it changes their perspective and releases God’s power in their lives. On learning that I was praying for my patients, a colleague asked me for more specific details. I explained that my prayers are very simple and go something like this: “Kind Father, it is a blessing to me that this precious person has come here today and in a small way is allowing me to share in their suffering. I lift this person up to you and ask for your healing touch in their life. I ask that you give grace to face this difficult journey and for power to overcome this bondage. May your peace and grace go with them until our next meeting.” I encouraged my colleague to always use the patient’s name when praying with them, as well as incorporate specific needs that arose during that day’s visit.


THE FIGHT OF OUR LIVES

Of the patients I saw during the six months I worked in the clinic, 169 were able to be tracked. Of those, 133 made it through detox and received at least one injection of XR-NTX. A total of 89 patients (67 percent) were still active at three months, 55 (41 percent) at six months and 27 (20 percent) at 12 months. Most studies track patients for 12 to 24 months, and our clinic continues to follow up on our patients even though I have returned to Kenya.

While many studies are available regarding XR-NTX, none of them compare to our situation. Our patients were not selected with a statistical study in mind, rather this is a retrospective observational assessment with the intention to treat. These addicts were self-referred, counselor-recommended, court-ordered from our local law enforcement and even sent from neighboring counties. The drug of choice was primarily heroin, but most were poly-substance, a few were alcoholic, some were on a number of prescription opiates and at least one was using only crystal meth. Patients not retained were difficult to follow and those who relapsed were not always known. Our goal was to have them in active treatment for 12 to 24 months. Some patients transferred into our program already on treatment that was started in other clinics.

A study released in Alcoholism & Drug Abuse Weekly compared usage of buprenorphine versus Vivitrol and showed both had 50 percent retention at six months. While our population was only at 41 percent, among the MAT clinics in communities like “real world” Southern Ohio, our program stood out as significantly more successful.

And in that real world, we are in the midst of the largest manmade epidemic in the history of the United States— the opiate epidemic. According to the U.S. Department of Health & Human Services (HHS), drug overdose deaths are the leading cause of injury death in the U.S. HHS has made prevention, treatment, research and effective responses to rapidly reverse opioid overdoses a top priority to help fight the epidemic.

As healthcare professionals, we are on the front lines of this crisis. Numerous experts say doctor training is key to dealing with the epidemic. Former U.S. Surgeon General Dr. Vivek Murthy sent a letter to millions of healthcare professionals in 2016 calling for a “national movement of clinicians” to help fight the opioid epidemic. In the letter, he wrote, “I know solving this problem will not be easy...But, as clinicians, we have the unique power to help end this epidemic.” He called for healthcare professionals to educate themselves first, screen patients for substance use disorders and connect them with treatment options, managing it as a chronic illness not a moral failing.

Christian healthcare professionals should be at the forefront of addiction medicine, because who else is better equipped to redirect patients who have lost their spiritual way? Yes, the drug-addicted patient is masterful at lying, cheating, stealing and manipulating. But if ever there was a group of people who are harassed and helpless, like sheep without a shepherd, it is this population.

And Jesus went throughout all the cities and villages, teaching in their synagogues and proclaiming the gospel of the kingdom and healing every disease and every affliction. When he saw the crowds, he had compassion for them, because they were harassed and helpless, like sheep without a shepherd. Then he said to his disciples, “The harvest is plentiful, but the laborers are few; therefore pray earnestly to the Lord of the harvest to send out laborers into his harvest” (Matthew 9:35-38, ESV). 

This Scripture has often motivated me in my ministry at Tenwek, and when I brought it with me to the MAT clinic, the compassion described in it became contagious. At one memorable appointment, a MAT patient told me how just that morning her husband had left her and their child, taking everything, even the diapers. I decided to run to a local drugstore across the street to buy baby supplies for her, but another staff member at the clinic insisted on giving me her debit card to pay for them. This inspired other staff toward acts of kindness, and it resulted in our patients leaving after each visit having experienced a compassion rarely shown to them outside the clinic.

I don’t want to minimize the team effort. Recovery from addiction is achieved through behavioral therapies. Vivitrol is a tool that provides a safety net while patients go to counseling, group sessions and 12-step programs, in addition to committing themselves to spiritual growth. During this time they make apologies, earn back trust and restore relationships. How long the injections continue depends on the progress the patients make in changing their behaviors. Coordinating all this takes a team, and in our office the behavioral health clinician was the key person to oversee this process, providing invaluable support to the clients and other staff. The CEO of Hopewell Health Center (the federally qualified community health center where I worked), the MAT program coordinator, the nurses and all the staff were supportive of the holistic approach and my attention to spiritual care.

At the end of six months, I had met with more than 200 drug-addicted patients from every walk of life—patients just like the couple who stopped me in the park that day. Like them, nearly all understand the connection between their addiction and their spiritual journey. And none of them refused my offer of prayer. This experience has convinced me that long-term sobriety is difficult, but without God’s power it is almost impossible. As a Christian healthcare professional, you have the unique opportunity to help your substance-addicted patients access all that the Almighty offers. What is holding you back from representing Him in your practice?


ABOUT THE AUTHOR

Stephen L. Manchester, MD, FAAFP, serves with World Gospel Mission at Tenwek Hospital in Kenya. He and his wife Theresa have been there since 2005. They have three boys: Nick, Peter and Wil. Steve is director of Tenwek’s hospice and palliative care services. He is from Chillicothe, Ohio where he practiced at Hopewell Health Center and the Ross County Health Department for 13 years and has degrees from Asbury University and Wright State University Boonshoft School of Medicine. Follow their ministry at facebook.com/manchestersoutthedoor.

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We are excited to now offer continuing education credits through Today's Christian Doctor. One hour of self-instruction is available for this article.

To obtain continuing education credit, you must complete the online test at https://www.surveymonkey.com/ r/2018opioidepid. This CE activity is complimentary for CMDA members. The fee for non-CMDA members is $50.00. For payment information, visit www.cmda.org/cepayment

If you have any questions, please contact CMDA’s Department of Continuing Education Office at ce@cmda.org.


CONTINUING EDUCATION
Review Date: January 25, 2018
Original Release Date: February 25, 2018
Termination Date: February 25, 2021

EDUCATIONAL OBJECTIVES 

  • Discuss how to integrate spiritual care into the daily practice of medicine.
  • Describe the use of long-acting naltrexone for the treatment of opiate addiction.
  • Describe how to help a patient through a period of opiate withdrawal.
  • Describe positive evidence for incorporating spiritual care into treatment of the opiate-addicted patient.

ACCREDITATION 
The Christian Medical & Dental Associations is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

PHYSICIAN CREDIT 
The Christian Medical & Dental Associations designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

 

DENTAL CREDIT 
CMDA is an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 1/1/2015 to 12/31/2018. Provider ID#218742. 1 Hour Self Instruction Available. No prior level of skill, knowledge, or experience is required (or suggested).

DISCLOSURE 
None of these authors, planners or faculty have relevant financial relationships. 
Stephen L. Manchester, MD; David Stevens, MD, MA (Ethics); Mandi Mooney, CMDA Today’s Christian Doctor Editor; Michael O’Callaghan, DDS; Barbara Snapp, CE Administrator; and Sharon Whitmer, EdD, MFT

CMDA CE Review Committee 
John Pierce, MD, Chair; Jeff Amstutz, DDS; Mike Chupp, MD; Lindsey Clarke, MD; Stan Cobb, DDS; Gary Goforth, MD; Elizabeth Heredia, MD; Curtis High, DDS; Bruce MacFadyen, MD; Dale Michels, MD; Shawn Morehead, MD; Michael O’Callaghan, DDS; David Stevens, MD (recused); and Richard Voet, MD

THERE IS NO IN-KIND OR COMMERCIAL SUPPORT FOR THIS ACTIVITY.

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