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The Elephant in the Room

Opioid addiction is an unfortunate epidemic which has recently surpassed motor vehicle related injuries as the 4th leading cause of death in the United States. In 2014, CDC reported that 18,893 deaths were related to overdose of opioid medications. And, sadly, Kentucky is the most afflicted state. (Graph 1 displays the rate of death from overdoses of prescription opioids in the United States more than quadrupled between 1999 and 2010.) These alarming trends triggered the Department of Health and Human Services (HHS) to deem prescription-opioid overdose deaths an epidemic and prompted multiple federal, state, and local actions. The objectives included 1) providing prescribers with the knowledge to improve their prescribing decisions and the ability to identify patients’ problems related to opioid abuse, 2) reducing inappropriate access to opioids, 3) increasing access to effective overdose treatment, and 4) providing substance-abuse treatment to persons addicted to opioids. Unfortunately, the most crucial objective, providing treatment to persons already addicted to opioids, was not emphasized!

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Opioid abuse and dependency causes a significant social, economic, and biomedical toll. Opioid substitution therapy has been proven to reduce illicit opioid use, lower rates of arrest and recidivism, decrease rates of disease transmission, and increase treatment compliance for co-occurring morbidities. The gold standard for the treatment of opioid addiction is Medication Assisted Treatment (MAT). In 2014, SAMHSA (Substance Abuse and Mental Health Services Administration) sponsored the investigation of evidence based practices (16 adequately designed Randomized Control Trials and 7 meta-analyses) specifically looking at the effectiveness of Buprenorphine. The conclusion was, “BMT [Buprenorphine Medication Assisted Treatment] is associated with improved outcomes [greater than 80% depending upon dosage and duration of treatment] compared with placebo for individuals and pregnant women with opioid use disorders.”1 The authors added, “BMT should be considered for inclusion as a covered benefit.”1 Additionally, the National Safety Council warned, while “…detoxification seems to be the most attractive [it does not involve the ongoing use of medications], in fact, this method is the least effective and may be the most dangerous [risk of overdose is extremely high].”

In 2011, NIH conducted a world-wide review, specifically examining the evidence for Buprenorphine misuse. The authors concluded, “Wherever there is access to any medication with abuse potential, diversion is likely to follow, making it unsurprising that buprenorphine diversion has been documented.”2 They stressed that despite the documented diversion, Buprenorphine products were clinically effective and safe for the treatment of opioid dependence. Buprenorphine’s safety profile, ceiling effect at high doses, and its ability to be co-formulated with naloxone to limit injection abuse and lower abuse potential compared to full opioid agonists make it a suitable medication for office-based treatment of opioid dependency. The authors recommended, “Strong consideration should also be given to the medical, social, public health, and economic benefits that arise when opioid-dependent individuals use buprenorphine in a therapeutic manner to self-treat addiction and withdrawal symptoms or as a harm reduction approach to manage the risks associated with drug dependence.”2

The key driver of the overdose epidemic is the underlying substance-use disorder (SUD). SUD is a chronic disease and similar to other chronic diseases (i.e., diabetes, hypertension), SUD is generally refractory to cure; but, effective treatment and functional recovery are possible. As the evidence-based medicine studies demonstrated, medication-assisted therapies (MAT) are available; but, these modalities are underutilized! Of the 2.5 million Americans 12 years of age or older who abused or were dependent on opioids in 2012 (according to the National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Services Administration [SAMHSA]), fewer than 1 million received MAT. A study of heroin-overdose deaths in Baltimore between 1995 and 2009 found an association between the increasing availability of methadone and buprenorphine and an approximately 50% decrease in the number of fatal overdoses.3

There are many barriers which contribute to low access and utilization of MAT. The most significant one is the misconception that MATs merely replace one addiction with another. The second barrier is the bias toward an abstinence model. As Jason Cherkis, Huffington Post author of “Dying to be free” questioned, if we have evidence-based medicine that demonstrated effectiveness of MAT, why are we not practicing it? And another barrier is policy and regulatory mandates which limit MAT in regards to dosages prescribed, annual or lifetime medication limits, and pre-authorization to reimburse for MAT.

The epidemic of prescription-opioid overdose is complex. Access to MAT is crucial for patients. It is also necessary to implement strategies to curb inappropriate prescribing of opioids. However, do not ignore the elephant in the room, treatment of already addicted patients!

References

1 Cindy Parks Thomas, Catherine Anne Fullerton, Meelee Kim, Leslie Montejano, D. Russell Lyman, Richard H. Dougherty, Allen S. Daniels, Sushmita Shoma Ghose, and Miriam E. Delphin-Rittmon. Medication-Assisted Treatment with Buprenorphine: Assessing the Evidence. Psychiatric Services 2014 65:2, 158-170

2Yokell MA1, Zaller ND, Green TC, Rich JD. Buprenorphine and buprenorphine/naloxone diversion, misuse, and illicit use: an international review. Curr Drug Abuse Rev. 2011 Mar;4(1):28-41.

3 Schwartz RP, Gryczynski J, O’Grady KE, et al. Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995-2009. Am J Public Health 2013;103:917-922

By Tuyen Tran, M.D.

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