Drug Addiction and the Case for Medication-Assisted Treatment

Published: 10/17/2016 2:54:11 PM
Modified: 10/17/2016 2:54:07 PM

Buprenorphine, an artificial opioid that has been available for more than a decade, has emerged as the not-so-secret weapon in the fight against opiate abuse. Those who prescribe buprenorphine have made “pioneering contributions to addiction treatment,” Nora Volkow, the director of the National Institute on Drug Abuse, said during a U.S. Senate hearing two years ago.

“Rigorous studies have shown (buprenorphine) to be effective, either alone or in combination with naloxone, in significantly reducing opiate drug abuse and cravings,” she said.

In addition to reducing drug overdoses, Volkow said, what is called medication-assisted treatment — using buprenorphine or other pharmaceuticals — “increases retention of patients in treatment and decreases drug use, infectious disease transmission, and criminal activity.”

The debate continues about the relative merits of buprenorphine and its better-known, older pharmaceutical cousin, methadone.

Compared with methadone, buprenorphine is less effective at killing pain and producing euphoria, “but nonetheless ameliorates withdrawal symptoms,” a 2012 article in the Journal of Neurosciences in Rural Practice found. Buprenorphine is effective for treatment of moderate levels of dependence and “probably the safer agent,” but still poses risks of being diverted for illicit use, according to the article.

High doses of methadone can cause cardiac arrest, but that risk is not associated with buprenorphine, according to guidelines published by the American Society of Addiction Medicine in 2015.

Both drugs must be taken daily. “Methadone clinics differ from other medication-assisted treatment programs (in that they) must abide by strict federal regulations and must be certified by and overseen” by state agencies, according to a 2014 report by the New Hampshire Center for Excellence, a state-funded technical assistance provider.

By comparison, certified doctors can prescribe buprenorphine, although federal rules limit to 100 the number of patients for which each doctor can provide the medication.

With methadone, “long-term treatment is often needed,” according to ASAM. By comparison, with buprenorphine “there is no recommended time limit for treatment,” the society says. The Groups program provides counseling for patients with buprenorphine prescriptions for up to two years.

The two drugs, while known to be effective, haven’t been fully deployed in the battle against addiction, Volkow said. “Medication-assisted treatments remain grossly underutilized in many addiction treatment settings, where stigma and negative attitudes (based on the misconception that buprenorphine or methadone ‘substitute a new addiction for an old one’) persist among clinic staff and administrators,” she told the senators. “Policy and regulatory barriers also can present obstacles.”

The efforts to cure addiction vary from state to state. In 2014, Volkow and other federal officials singled out Vermont for its efforts to promote the use of medication-assisted treatment stretching back as far as 12 years. They pointed to efforts to provide a two-tier system of care where patients with complex addictions or mental illness would get care in specialty treatment centers called “hubs.” Those with less complex clinical needs would receive medication and related services from physicians and other care-givers in less-intensive settings called “spokes.”

Vermont spent $36 million to care for 11,500 patients in that system, according to a December 2015 report from the state Department of Health.

New Hampshire has lagged behind. Medication-assisted treatment “services are limited and desperately needed,” warned a report issued in January by the Bureau of Drug and Alcohol Services of the New Hampshire Department of Health and Human Services.

That treatment is lagging behind the opioid problem in the Granite State is evidenced by “the sharp increases in emergency room visits and ambulance calls for opioid abuse, in opioid-related overdose deaths, and in the wait lists reported by all of the state’s eight methadone clinics, with lengths of waitlists ranging from two weeks to two months,” the report found.

— Rick Jurgens

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