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May 2, 2019

Medication-Based Treatment to Address Opioid Use Disorder

Author Affiliations
  • 1American Association for the Advancement of Science, Potomac, Maryland
  • 2National Academy of Medicine, Washington, DC
JAMA. 2019;321(21):2071-2072. doi:10.1001/jama.2019.5523

The opioid epidemic was declared a national public health emergency on October 26, 2017, and, although there have been some significant increases in federal funding and new programs to address this crisis, progress appears to be slow and the United States continues to be severely affected by substance use disorder.1 As of 2016, approximately 2 million individuals in the United States have been diagnosed with opioid use disorder (OUD),1 and an estimated 130 people die every day from a drug overdose.2 To reverse these unacceptable trends, all evidence-based tools must be utilized. Specifically, medication-based treatment, which has been proven to be effective in treating substance use disorder and saving lives, has been severely underutilized for decades. According to 2019 estimates, “less than 35 percent of adults with OUD had received treatment for opioid use in the past year and no national data sources are currently available to precisely estimate the share of those patients who are being treated with one of the three US Food and Drug Administration (FDA)-approved medications.”1

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    3 Comments for this article
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    Agonist Treatment is Substituting one Drug For Another
    Thomas Hilton, PhD | Retired
    Leshner and Dzau's assertion that “the public’s mistaken belief that taking medication is ‘just substituting one drug for another’" was surely meant to blunt resistance from abstinence-oriented treatment adherents. However, drugs like buprenorphine and methadone are opioids. If people enrolled in such medication-assisted treatment (MAT) stop taking their medications they will go into withdrawal as if they stopped using heroin. McKay, McLellan, Laudet, Jason, White, and others (1-5) have reported that without long-term recovery support after enrollment in treatment, relapse is the norm. The dilemma is that studies show it takes about 5 years of abstinence before the odds of relapse become unlikely. In contrast, patients on MAT must adhere to their medical regimen for the remainder of their lives just like diabetics on insulin must. Numerous studies show that the vast majority patients who are addicted and in MAT have dropped out of treatment in under 2 years.

    The authors also assert that MAT is efficacious. What is yet to be demonstrated is superiority in effectiveness relative to other treatment modalities in keeping patients in recovery from relapsing to use. In this respect, MAT experiences the same degree of relapse as any other intervention - which is very high.

    Many authors have asserted recently that easing access to prescription opioids like oxycodone caused or contributed to the steep increase in US opioid addictions and overdoses. It is therefore ironic, that there is a blitzkrieg of politicking to reduce or eliminate training requirements and limits for general practice physicians to prescribe opioid agonists. One reasonable concern is that patients presenting with addiction concerns might be started on MAT without valid assessment that their use meets the DSM criterion for opioid addiction. Moreover, without effective engagement in behavioral therapy, relaxing MAT policy risks fueling the addiction bonfire rather than extinguishing it.

    References

    1. McKay, J.R. (2005). Is there a case for extended interventions for alcohol and drug use disorders? Addiction, 100, 1594-1610.

    2. McLellan, T. (2010). What is recovery? Revisting the Betty Ford Institute Consensus Panel Definition The Betty Ford Consensus Panel and Counsultants. Journal of Substance Abuse Treatment, 28, 200-201.

    3. Laudet, A. B., & White,W. (2010).What are your priorities right now? Identifying service needs across recovery stages to inform service development. Journal of Substance Abuse Treatment, 38, 51–59

    4. Jason, L.A. and Ferrari, J.R. (2010). Oxford House Recovery Homes: Characteristics and Effectiveness. Psychological Services, 7(2), 92-102.

    5. White, W.L. (2009). The mobilization of community resources to support long-erm addiction recovery. Journal of Substance Abuse Treatment, 36, 146-158.

    6. Dupont, R.L, Compton, W.M., & McLellan, A.T. (2015). Five-year recovery: A new standard for assessing effectiveness of substance use disorder treatment. Journal of Substance Abuse Treatment, 58, 1-5.

    7. Dennis, M.L., Foss, M.A., & Scott, C.K. (2007). An eight-year perspective on the relationships between the duration of abstinence and other aspects of recovery. Evaluation Review 31(6), 585-612.

    8. Hser, Y-I, Evans, E., Grella, C., Ling, W. & Anglin, D. (2015). Long-term course of opioid addiction. Harvard Review of Psychiatry, 23(2), 76-89.
    CONFLICT OF INTEREST: None Reported
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    Correcting Common Misconceptions About OUD Treatment
    Richard Saitz MD, MPH, FACP, DFASAM | Chairman and Professor, Department of Community Health Sciences, Boston University School of Public Health
    Dr Hilton (above) and others question the role if not the propriety of using opioid agonists for treatment of opioid use disorder. Many randomized trials show superiority of medication over placebo on multiple outcomes for opioid use disorder (1,2). Few trials that have compared psychosocial treatment alone to control have shown that psychosocial interventions are efficacious, and these have largely been studies of contingency management, which is not widely available (3). Studies that compare medication vs psychosocial treatments find in favor of medication; eg one randomized comparison of buprenorphine vs placebo in patients who received both group and individual counseling had ~75% retention at one year and 75% of urine drug tests negative in the buprenorphine group, versus zero retention in the placebo group (4).

    On the basis of available empirical evidence, medication treatment should be widely disseminated, and psychosocial treatment should be provided when needed as an adjunct. Medication treatment should never be withheld because a patient chooses not to avail themselves of psychosocial treatment. Psychosocial treatment alone can be used if it has worked well for the patient before, if they have mild OUD, if they have solid social support with few comorbidities or concomitant social ills, or if they have a strong preference for it and are made aware of the risks of choosing a treatment that has less evidence for efficacy.

    Methadone and buprenorphine are different from other addictive opioid agonists. Because of their pharmacological properties they are not commonly misused nor are they often ‘drugs of choice’ by people with OUD. And when used in treatment they do not reproduce the erratic highs and lows that heroin and other opioids used illicitly do. What is ironic is that when buprenorphine is misused, the main reason is to self-treat opioid use disorder and withdrawal, not to use it as a main drug of addiction or to achieve euphoria. The reason for this self-treatment is the widespread difficulty accessing medication treatment for opioid use disorder that forces patients to self-treat from illicit sources of medication.

    References:

    1. Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev 2014; :CD002207.

    2. Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev 2009; :CD002209.

    3. Petry NM, Carroll KM. Contingency management is efficacious in opioid-dependent outpatients not maintained on agonist pharmacotherapy. Psychol Addict Behav 2013; 27:1036.

    4. Kakko J, Svanborg KD, Kreek MJ, Heilig M. 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a randomised, placebo-controlled trial. Lancet 2003; 361:662.
    CONFLICT OF INTEREST: Associate Editor, JAMA
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    Overlooks Something of Importance
    Steven King, M.D.,M.S. | Pain Management Physician
    This article indicates the authors are not fully knowledgeable about the issue of opioid use disorder (OUD).

    While we know a great deal about OUD related to the illicit use of opioids, we know very little about iatrogenic OUD where patients are prescribed opioids for a legitimate pain complaint and then develop OUD as a result.

    As far as I'm aware there is virtually no literature on the appropriate treatment of iatrogenic OUD. In fact if methadone and buprenorphine are the treatment for it, then, as they are both as good analgesics as the other opioids, they should
    be the first line opioids for pain as we would have a unique situation where the drug causing the adverse event would also be the treatment for it.
    CONFLICT OF INTEREST: None Reported
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