Medication-Assisted Treatment: A Vital Player in the Opioid Epidemic

By | August 15, 2018
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For two years in a row, the United States has experienced a decrease in life expectancy, which researchers have largely attributed to the opioid epidemic. Life expectancy for the United States population was 78.6 years in 2016, a decrease of 0.1 year from 2015 [PDF]. Age-specific death rates between 2015 and 2016 increased for younger age groups, which is attributed to the rapid increase in opioid overdose deaths. Prescription and illicit opioids were involved in at least 42,249 deaths in 2016, which equates to a five-fold increase in the opioid overdose death rate since 1999. According to the Centers for Disease Control and Prevention (CDC), at least 115 Americans die every day from an opioid overdose.

In a recent article published in Medical Care, Huskamp, Riedel, Barry, and Busch address the magnitude of the opioid epidemic and evidence-based medical treatment for opioid use disorder (OUD). The US Food and Drug Administration has approved three medications for treatment of OUD: methadone, buprenorphine, and naltrexone. The authors found that many Marketplace plans either do not cover, or require prior authorization for, these medications. Unfortunately, these insurance restrictions are often more common for OUD treatment medications than for short-acting opioid pain medications.

All three medications have proven efficacy, but each drug has various side effects, adherence limitations, and risk for diversion that providers must consider when initiating treatment for patients with OUD. Methadone is a full opiate agonist, which means that it resembles other opioids, and it saturates opioid receptors in the brain. Because of this, methadone has the potential to induce respiratory suppression when administered in doses that are greater than an individual’s opioid tolerance. For this reason, methadone is dispensed through licensed and highly regulated outpatient specialty opioid treatment programs in an effort to decrease methadone-associated deaths.

Buprenorphine is a partial opiate agonist, also used to saturate opioid receptors in the brain, but has much less potential for abuse, as partial agonists prevent the typical high expected of full opiates. Buprenorphine is prescribed in clinic-based settings on a weekly to monthly basis (individualized to meet the needs of each patient’s recovery process) and is a very safe drug, particularly given minimal risk of overdose and decreased risk for abuse. Buprenorphine is often combined with Naloxone (i.e. Suboxone) to further reduce risk for diversion. However, buprenorphine is highly regulated by the Drug Enforcement Agency (DEA), and providers can only prescribe it after completing a mandatory 8-hour training (with additional hours for mid-level providers) and obtaining a waiver– all of this required for a medication far safer than the short-acting opioid pain medications that providers prescribe everyday without any special training.

Finally, naltrexone is an opiate antagonist that saturates opioid receptors in the brain, which prevents individuals from experiencing the euphoric effects of drugs like heroin or fentanyl. It is essentially a “blocker” and reduces cravings for both opioids and alcohol. Naltrexone can be prescribed daily in oral pill form or via a monthly injection. Naltrexone is a very safe drug and has no risk for abuse or overdose.

Being on one of these three drugs is critical to prevent overdose and death, especially in early recovery. With medication-assisted treatment, 50-60% of patients will still be in recovery one year later. Among patients who detox from opiates and are discharged from treatment without medication, 90% are at risk of relapse within two months. If those patients return to their previous usage, they are at high risk of overdose, especially since the majority of street-bought “heroin” these days is actually fentanyl, which is 50-100 times more potent than heroin.

I have worked with many patients with OUD, and two of these experiences have deeply affected my understanding of addiction and my advocacy for medication-assisted treatment. The first was a 31-year-old woman—outgoing, optimistic, smart, beautiful, and happy. I met her while working in an evidence-based outpatient addiction clinic during medical school. She had initially presented to the clinic about 6 months before our meeting and had transitioned from IV heroin to Suboxone at that time. At the time I met her, she had a stable job, a supportive partner, a home to live in, food to eat, and felt happy. She didn’t “look like” an IV heroin addict, but I learned that day why she initially turned to drugs. She was gang-raped at the age of 19, and after this traumatic event, she was psychologically struggling and didn’t know where to turn. She initially used pills, then turned to IV heroin. She used heroin for a decade. Her transition to Suboxone, combined with robust psychosocial wraparound services at the addiction clinic, changed her life.

The second was a 32-year-old woman whom I met in the intensive care unit (ICU) after overdosing on IV heroin, laced with fentanyl, and going into cardiac arrest. Her heart had stopped beating for approximately 10-30 minutes before someone found her. She was given CPR, a heartbeat returned, and she was transferred to the closest tertiary healthcare center for intensive care. I cared for her in the ICU for a week before she was declared brain dead. I met her parents and siblings who shared her story of a difficult childhood, abusive intimate relationships, a struggle with opioid addiction, and now, her story of death… a tragic death that might have been prevented had she had access to medication-assisted treatment.

Authors from the recently published Medical Care article conclude that governmental regulators tasked with enforcement of the Mental Health Parity and Addiction Equity Act, an act that requires standards for formulary design for mental health and substance use disorder drugs be comparable to those for other medications, should focus their attention on formulary coverage for medication-assisted treatment, including methadone, buprenorphine, and naltrexone. Others have argued, and I agree, that mandatory training for providers in order to obtain the buprenorphine waiver (which only then allows providers to prescribe the medication) is a significant barrier to care. The DEA should remove this barrier so that all providers can prescribe this very safe, life-saving medication to patients who need it.

Primary care physicians are well-positioned to provide medication-assisted treatment in the outpatient setting and hence, increase access to care. In addition, PCP-based treatment can de-stigmatize addiction and provide a much-needed patient-centered medical home approach that embraces comprehensive, coordinated, longitudinal care, and also considers patients’ social determinants of health. Addressing this epidemic requires that we consider the entire individual, including the biological, psychological, and social aspects of each individual’s disease of addiction.

 

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Rebekah Rollston

Rebekah Rollston

Rebekah L. Rollston, MD, MPH, is a Family Medicine Physician at Cambridge Health Alliance, Instructor in Medicine at Harvard Medical School, Faculty of the Massachusetts General Hospital Rural Health Leadership Fellowship (in partnership with the Indian Health Service Rosebud Hospital), Editor-in-Chief of the Harvard Medical School Primary Care Review, and Head of Research at Bicycle Health, a digital health startup that provides biopsychosocial treatment of opioid use disorder via telehealth. She earned her Medical Degree from East Tennessee State University Quillen College of Medicine (in the Rural Primary Care Track) and her Master of Public Health (MPH) from The George Washington University Milken Institute School of Public Health. Dr. Rollston’s professional interests focus on social determinants of health & health equity, gender-based violence, sexual & reproductive health, addiction medicine, rural health, homelessness & supportive housing, and immigrant health.
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About Rebekah Rollston

Rebekah L. Rollston, MD, MPH, is a Family Medicine Physician at Cambridge Health Alliance, Instructor in Medicine at Harvard Medical School, Faculty of the Massachusetts General Hospital Rural Health Leadership Fellowship (in partnership with the Indian Health Service Rosebud Hospital), Editor-in-Chief of the Harvard Medical School Primary Care Review, and Head of Research at Bicycle Health, a digital health startup that provides biopsychosocial treatment of opioid use disorder via telehealth. She earned her Medical Degree from East Tennessee State University Quillen College of Medicine (in the Rural Primary Care Track) and her Master of Public Health (MPH) from The George Washington University Milken Institute School of Public Health. Dr. Rollston’s professional interests focus on social determinants of health & health equity, gender-based violence, sexual & reproductive health, addiction medicine, rural health, homelessness & supportive housing, and immigrant health.