Fighting the Opioid Epidemic

In 1999, there were twice as many deaths from motor vehicle accidents as there were fatal drug overdoses.  By 2104, these numbers changed dramatically, with there being 47,055 drug overdose deaths compared to 29,230 deaths from car crashes.  Over 60% of the drug overdose deaths were from prescription opioids or heroin, with nearly twice as many deaths associated with the prescription pain medications than heroin. 

The rise in these opioid deaths is due in large part to the increased writing of opioid prescriptions in recent years.  On an average day, more that 650,000 opioid prescriptions are dispensed, and in 12 states, primarily in the South, Midwest and Rustbelt, there are more opioid prescriptions written annually than people who live in these states.  Each day 3,900 people initiate nonmedical use of prescription opioids, 580 people initiate heroin use, and 78 people die from an opioid-related overdose. 

In July 2016, Congress, with bipartisan support, passed the Comprehensive Addiction and Recovery Act (CARA), but did not provide any additional federal funding to address the opioid epidemic.  Finally in September 2016, Congress passed spending bill, which included $37 million to begin funding CARA.

In order to address the epidemic, a few priorities have been identified.  First is to improve the prescribing practices among providers who can prescribe opioids.  Second is to expand access to and increase the use of medication-assisted treatment.  Third is to expand the use of naloxone.  Let me review each of these items.

Twenty or so years ago it was decided that pain was under diagnosed and under treated, so physicians and mid-level prescribers were encouraged to more aggressively treat pain.  While clearly there were some patients with chronic pain who needed this approach, the problem was that the use of opioids increased across the board, helped along by the pharmaceutical companies, who encouraged this practice.  The correct prescribing of opioids, which should primarily be used for a very short time for most patients, often was not followed, and thus patients became dependent on these medications, developed a tolerance requiring high doses, and some became addicted.  Those who became addicted would start to doctor shop, and when they could no longer get their prescription filled, they often switched to heroin, which was cheaper on the street to buy than prescription opioids.  Systems are now in place to track prescriptions of controlled substances, but education and training of providers is what is needed to prevent people from getting addicted, and to provide better treatment to those with acute and chronic pain.

Medication-Assisted Treatment or MAT is a popular term used today to describe medications used for addiction treatment.  Many in the addiction field are at best ambivalent about the term MAT, since they feel that just the term medication should be used, just like in other areas of medicine.  The medications for opioid addiction are methadone, buprenorphine, naltrexone, and naloxone. 

Methadone is a long acting opioid, which can be used for both detoxification and maintenance.  It is a highly controlled substance and primarily used in opioid treatment programs (OTPs).  Individuals in OTPs need to come daily to get their methadone, but over time they can get medication to take home, if they are compliant with the rules of the program and are not using other addictive substances.  Methadone has been found to be very effective, based on over 50 years of research, but many people do not like having to go to a clinic daily to get their medication.

Buprenophine is a newer medication, which is not as strong as methadone or heroin.  It is a partial agonist compared to a full agonist, like heroin or methadone.  The most common form of buprenorphine goes under the brand name of Suboxone, which is 4 parts buprenorphine and 1 part naloxone.  The naloxone is included to prevent diversion, since the medication only works if you place it under your tongue and let it dissolve.  Suboxone prescriptions are now being written and patients can take their medication at home.  Still, it is important for patients to also enroll in psychosocial treatment programs, since no medication teaches you how to cope, manage stress, live a healthy lifestyle, and improve social and family relationships.

Naltrexone is an antagonist and simply blocks the effects of opioids on the mu receptor in the brain.  It reduces cravings, and if a patient takes an opioid while on naltrexone, it will block the effect.  Thus, it is a relapse prevention medication and has no psychoactive or addictive properties.  Most people taking the pill form of naltrexoone don’t stay on it, so a long-acting injectable form of naltrexone, called Vivitrol, is now being prescribed.  The medication lasts 30 days and removes the issue of taking a pill daily.

Naloxone is a short-acting version of naltrexone, and is being sold to friends and family members who come in contact with people, who use opioids and could overdose.  It is the same medication that paramedics use to revive people who have overdosed, and is best known under the brand name of Narcan.  Naloxone needs to be administered as soon as possible after a person overdoses, since by the time the paramedics arrive it is often too late.  Naloxone is now available without a prescription in California and can be purchased at most pharmacies.  Also, Medi-Cal (Medicaid in other states) now will pay for it.  The hope is that enough people will have naloxone with them, just like people with allergic reactions carry epi-pens, in order to save lives. 

If you have any questions or comments, feel free to email me at ken@psychsem.com.