A malpractice case holds lessons for opioid addiction treatment

In January 1979, 41-year-old Raphael Osheroff, MD, a nephrologist, was admitted to Chestnut Lodge's Maryland facility with anxiety, depression and thoughts of suicide after outpatient treatment proved unsuccessful. He suffered from major depression. Chestnut Lodge’s medical staff (trained in psychodynamic psychotherapy and unwilling to use evidence-based psychotropic medications) prescribed for Osheroff psychotherapy four times a week for the treatment of narcissistic personality disorder. The staff claimed that any medication would mask his symptoms and interfere with the process of recovery.

Osheroff's condition worsened, and in September of that year, after seven months of unsuccessful and costly treatment, he was transferred to Silver Hill Foundation and was prescribed psychotropic medication. According to reports, his condition began to improve shortly after taking the medication. In the process, however, Osheroff lost his medical practice and ended up estranged from his family.

Osheroff’s treatment at Chestnut Lodge led to a lawsuit claiming that administrators and doctors committed malpractice by treating his severe depression with talk therapy alone when proven medications (antidepressants and mood stabilizers) were available. Osheroff won an arbitration board hearing, but both parties refused the financial award. Osheroff amended his complaint to include even more damages. The case was settled out of court in 1987. Following the settlement, Chestnut Lodge began to use medication treatment more regularly, until the Maryland center closed in 2001.

Osheroff v. Chestnut Lodge has become a landmark case in forensic psychiatry. After Osheroff, no reputable mental health practitioner will recommend treating severe major depression with psychodynamic psychotherapy alone. Previous to the case, many therapists thought, “We have to get to the root of the problem, and medications will just mask the symptoms.” The case showed mental health practitioners that they could be held liable for basing their treatment choices on intuition and personal belief rather than scientific evidence. It set a precedent that the addiction treatment community should consider in light of today’s treatment of opioid addiction.

Effective medications available

We are in the midst of an opioid crisis. Drug overdose is the leading cause of accidental death in this country. Prescription pain relievers accounted for nearly 19,000 of a total of just over 47,000 accidental overdose deaths in 2014—40%. Heroin addiction accounted for 22%, or 10,574 deaths that year. This is an epidemic that is affecting men and women, young and old, regardless of race or economic status.

Buprenorphine is a highly effective medication, which is why President Bill Clinton in 2000 signed into law the Drug Abuse Treatment Act (DATA), which allowed physicians access to participate in medication-assisted treatment (MAT) and to prescribe the drug to persons with opioid dependence. Data show that buprenorphine (and methadone) retains more patients in treatment, decreases HIV and hepatitis cases among IV drug users, decreases the number of overdose deaths, and decreases patients’ costly involvement with the legal system.

Despite clear evidence of these medications' effectiveness and their emphatic endorsement by the National Institutes of Heath (NIH) and the World Health Organization (WHO), only about 20% of persons who enter treatment for opioid dependence in the U.S. are provided medication to manage cravings. Many addiction treatment providers refuse to offer medications to persons with opioid dependence, claiming, as in the Osheroff case, that medications will only mask the problem and prevent true recovery. Many inpatient facilities refuse to treat patients who already are receiving medication for opioid dependence, and the 12-Step program Narcotics Anonymous (NA) won’t allow persons taking buprenorphine or methadone to participate actively in meetings (this is cited in NA's bulletin #29).

Why the pushback against this successful treatment option? Part of the problem is access. According to a 2014 study, only 3% of primary care physicians and 16% of psychiatrists had received the DATA waiver to prescribe buprenorphine for opioid addiction. When DATA was introduced, it allowed prescribers to have no more than 30 patients at one time at the start and then to be able to treat up to 100. That maximum number will now increase to 275 but, when faced with the estimated 2.4 million people addicted to prescription painkillers or heroin, there simply aren’t enough MAT prescribers to go around.

Another part of the problem involves the “abstinence-only” culture of some addiction treatment providers who fail to embrace scientific findings that support MAT. Just as the psychodynamically oriented clinicians at Chestnut Lodge did, these providers make treatment recommendations based on their opinions and biases, not on data and science. Their well-meaning but misguided efforts add to the problem, because abstinence-only programs for opioid-dependent patients have very low retention rates. Patients experience repeated failures in often costly residential programs (families go to financial extremes to cover facilities that will offer acupuncture, equine therapy and massage, but not MAT). Abstinence-based treatment centers regularly discharge patients into their trigger-laden natural environment without any anti-craving medication. Patients’ reduced tolerance to opioids following inpatient treatment increases their risk for fatal overdose.

Possibly the largest obstacle to providing MAT is education and understanding. Many residential treatment facilities and 12-Step programs across the country maintain the traditional view that a person isn’t sober unless he/she is completely abstinent from psychotropic drugs and medications. Yet if you simply define recovery by improvement in functioning, it is clear that MAT facilitates recovery from addiction far more effectively than psychosocial treatment alone.

Spreading the word

Families seeking treatment for their loved ones often don’t know about MAT and aren’t made aware of it by abstinence-only facilities and programs. This omission does a disservice to families and patients who expect treatment professionals to offer them options based on science and not opinion. The published data clearly show that patients on MAT have fewer instances of relapse and a better chance of staying engaged in and dedicated to their treatment.

Fortunately, the conversation about MAT is growing. The federal government has made MAT a priority in the war on drugs, so funding opportunities will begin to be linked to treatment facilities’ willingness and ability to modernize their views and implement MAT. With the opioid epidemic uncontained, and more families faced with the unfortunate reality of opioid addiction, there is hope that it won’t take a lawsuit such as the Osheroff case for the addiction treatment community to take notice of—and begin utilizing—effective medication-assisted treatment.

Luis Giuffra, MD, PhD, is Medical Director of Clayton Behavioral, a St. Louis-based group of mental health professionals from the fields of adult psychiatry, child and adolescent psychiatry, psychology, clinical social work and professional counseling, including addiction treatment programs from detoxification to maintenance. Clayton Behavioral's addiction treatment program incorporates and promotes the use of medication-assisted treatment in its evidence-based treatment protocols. Giuffra is a Professor of Clinical Psychiatry at Washington University in St. Louis.