Fighting opioid addiction with the help of medication

June 23, 2016 | by Edward-Elmhurst Health
Categories: Healthy Driven Minds

This blog post was updated on July 6, 2016.

Every day, 78 Americans die of an opioid overdose. This is a national  and local — crisis that demands additional treatment methods and better access to those options.

President Obama in February 2016 proposed spending $1.1 billion over the next two years to expand access to treatment for opioid addiction. The bulk of that money is earmarked for medication-assisted treatment (MAT), which typically refers to medications used in treating opioid use disorder.

MAT isn’t a new concept, but it’s controversial and not widely understood. I’d like to take time to explain what medication-assisted treatment is, its pros and cons, and what’s next in the fight against opioid addiction, including a new treatment approved in May 2016 by the Food and Drug Administration (FDA).

How does medication-assisted treatment work?

For many years, substance use disorders were primarily treated with psychosocial methods such as individual and group counseling. These treatments, combined with support groups and 12-step programs, have been and continue to be successful in treating many types of addiction.

However, opioids are different. Opioid withdrawal symptoms are so intense that it can be difficult for someone to even get started on the road to addiction recovery. Medication-assisted treatment is used as part of a comprehensive treatment program that includes behavioral therapies such as counseling. It helps manage addiction so those therapies can begin and be maintained. While these medications could be used for many years, once an individual is stabilized and their addiction is under control, we may discuss transitioning off the medication.

In the 1960s, methadone was introduced in the United States as a way to curb opioid withdrawal and cravings. Since then, more options to medically treat opioid addiction have come on the market:

  • Methadone: It lessens the painful symptoms of opioid withdrawal and blocks some of the euphoric effects of those drugs. Methadone comes in pill, liquid or wafer form and needs to be taken daily at a facility which is a licensed opioid treatment program (OTP).
  • Buprenorphine (Suboxone, Zubsolv, or Bunavail): Much like methadone, this suppresses withdrawal symptoms and cravings for the abused drug. Buprenorphine treatment was introduced in the U.S. in 2002, and while similar to methadone, it is less prone to abuse and lasts longer. It is typically given as a pill or a dissolvable film for daily use, but unlike methadone it can be prescribed by a certified physician and taken at home.
  • Probuphine: This is the newest medication-assisted treatment, getting FDA approval in May 2016. It consists of four rods the size of matchsticks implanted under the skin that offers controlled release of buprenorphine for six months.
  • Naltrexone: This medication works differently than methadone and buprenorphine by blocking the euphoric and other effects of opioids. If a person on naltrexone relapses, they would not get the high they normally would get from the abused drug. In 2007, the FDA approved an extended-release naltrexone injection (Vivitrol), which lasts four weeks.

The main controversy is that the first three of these medications are themselves opioids. But they don’t produce as much of an addictive use pattern as other opioids, and they can protect people from the cravings and withdrawal.

Isn’t MAT just substituting one drug with another?

This is the big stigma surrounding medication-assisted therapy. Many people think the only true way to fight addiction is recovering without the use of medications. Some people certainly can and do fight opioid addiction without medication, but most people relapse early in recovery. Medications provide a little extra help, and the result is significantly lower relapse rates.

Now, MAT isn’t a perfect treatment. There are downsides and barriers to how the treatment is administered.

Because these medications are opioids, they’re prone to abuse. It’s rare, but it happens. While their effects are different than other opioids, they do have some street value. They also continue the physical dependence on an opioid. If you stop taking the medication, you will go into withdrawal.

Opioid withdrawal can cause muscle aches, diarrhea, abdominal cramping, nausea, and vomiting. Patients often tell me they didn’t continue using the drug to get high, but instead to keep from getting sick. By using medication to ease withdrawal symptoms, it’s much easier for patients to begin other therapy methods to fight their addiction. 

Medication-assisted treatment requires a strong commitment from the patient. To be most effective, these medications need to be taken consistently, and for most of them, that means daily. Patients who take methadone need to go to a clinic to get their daily dose, which can present time and transportation problems. Even with the naltrexone shot, which is given monthly, I often see patients stop coming after a few months.

Another barrier is that not every substance abuse program offers medication-assisted treatment because not every physician is certified to administer it. Doctors must complete special training and become licensed to use these medications  it’s not just part of getting your M.D. In the case of buprenorphine, physicians can only prescribe the drug to a limited number of patients at any given time – although the federal government recently eased this rule. Even so, it can still be difficult for patients to find a physician who can administer medication-assisted treatment.

Still, research has found that when combined with behavioral therapy, MAT can significantly reduce opioid use and crime rates, prevent infections such as HIV from non-sterile drug abuse equipment, keep people in treatment longer, and improve their quality of life. We haven’t found similar medications to be as effective for any other substance use problems so far. We just need to be cautious and careful about the way we implement the treatment  as we would with any medical condition.

Addiction is a disease. It’s not a simple choice, behavior or moral failing. We would not withhold medication to treat other diseases. As with treatment for any disease, we try to minimize the risks of that medication. Physicians are responsible for closely monitoring patients and making sure they are properly using the medication, including taking it on time and at the recommended dose.

How can we expand access to addiction treatment?

The president is absolutely right. We need to expand access to addiction treatment. Of the 22.7 million Americans who needed drug or alcohol treatment in 2013, only 11 percent got it. Some of those who felt they needed treatment did not get help by choice, but 316,000 reported trying and failing to get treatment. To turn this around, we need to do two things in particular:

1. Increase the number of treatment facilities and health care providers

When someone decides they are ready to confront their addiction, time is of the essence. If there are no treatment facilities in the area or the facilities have long wait lists, that person may not have the resources to travel or be able to stay motivated until they can get a spot in the treatment program.

The availability of medication-assisted treatment needs to be more widespread. The Department of Health and Human Services on July 6, 2016, took a step in that direction. The organization increased the number of patients that a physician prescribing buprenorphine is allowed to treat from 100 to 275. This treatment requires more work by the physician – from training to needing to see each patient frequently. But for physicians who are dedicated to MAT, this is an encouraging development.

We see hundreds of patients with opioid use disorders come through our doors every year. In order to meet the needs of our community, Linden Oaks Behavioral Health Services made a commitment that all of our physicians have the required training to administer medication-assisted treatment.

2. Make treatment more affordable

Deductibles, co-pays and other cost barriers put treatment out of the grasp of too many people. While the Affordable Care Act mandates coverage for substance use disorder treatment, a June 2016 survey by the National Center on Addiction and Substance Abuse found that more than two-thirds of state benchmark plans violate federal requirements in this area.

I encourage lawmakers to expand and clarify coverage requirements. While the ACA requires plans to cover addiction treatment, it doesn’t specify which benefits should be covered. For example, many insurance companies require doctors to complete difficult authorization procedures for buprenorphine, and many refuse to cover methadone treatment at all. It just doesn’t make sense to me why you wouldn’t cover one of the treatments proven most effective for opioid addiction. 

What’s next in the fight against opioids?

Along with expanded access and better affordability, I think there are a few additional things we can do to help people in our community fight opioid addiction  and potentially save their lives.

Develop new treatment methods

I was glad the FDA approved the buprenorphine rods. What we’ve seen so far from the research is positive. This device won’t be right for all patients, but some will benefit greatly from it. They won’t have to worry about taking medication every day, getting refills every month, or, because it’s hidden under the skin, having friends or co-workers know they’re taking it. It also eliminates the risk of a patient turning around and selling the medication on the street. We need to keep working to develop treatment methods that improve patients’ odds of success.

Expand access to naloxone

Naloxone is not a medication-assisted treatment, but instead prevents opioid overdoses by reversing the toxic effect of the drug. It’s administered through an injection or nasal spray. Make no mistake, this drug saves lives. The Centers for Disease Control and Prevention (CDC) said more than 26,000 overdoses were reversed between 1996 and 2014 thanks to naloxone.

It’s become routine over the past few years for emergency responders to carry naloxone, and there’s been a push to make it even more accessible. Illinois residents will be able to buy naloxone over the counter sometime in 2016. We talk to our patients about where to get naloxone and how to use it in case they relapse. If they have been abstinent for a while, their tolerance may have gone down. This can increase the chance of overdose, so we want them to know how they can reduce their risk of death. 

Examine how we prescribe opioids

Doctors need to take some blame for the opioid crisis. We’ve been overprescribing opioids for too long. To help combat this, the CDC in March 2016 issued revised guidelines for prescribing opioids for chronic pain.

This is a good start, but we also need to make sure we’re diligent in meeting with patients consistently, keeping track of how much and how often we’re prescribing opioids, and watching for red flags such as if they ask for a refill early. Educating patients about best practices, risks and alternatives to opioids also needs to be a priority.

One advantage we have in Illinois is the presence of a strong prescription monitoring program, which physicians use to look up patients’ prescription history to help prevent abuse. Not all states have this, but I look forward to the day these programs are nationwide.

Our country’s opioid addiction problem didn’t happen overnight, and it won’t be fixed overnight, either. But together  as doctors, patients and community members  we can turn the tide.

If you would like to learn more about medication-assisted treatment and how it may help you or a loved one battle opioid addiction, fill out this assessment form online, and one of our team members will contact you. You also can call us at 630-305-5027.

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