“A great part of the tragedy of this opioid crisis,” wrote Nora Volkow on Tuesday, “is that … we now possess effective treatment that could … save many lives, yet tens of thousands of people die each year because they have not received these treatments.”
Volkow, the director of the National Institute on Drug Abuse, was prompted to write these words by a study reaffirming both the efficacy of medication-assisted treatment (MAT) for opioid addiction, and that treatment’s “gross under use” in practice, as she and her co-author, Erik Wargo, put it.
The study, led by Marc Larochelle, MD, of Boston Medical Center, was published in the Annals of Internal Medicine, also on Tuesday. It looked back at what became of the more than 17,500 adults in Massachusetts who suffered nonfatal opioid overdoses between January 2012 and December 2014. In the year after their overdoses, only 30 percent of them received any of the three FDA-approved medications for opioid addiction: methadone, buprenorphine, or naltrexone. As low as that percentage is, it’s probably more than would be true in most states, because Massachusetts (home of “RomneyCare”) has more universal health insurance than most.
The low level of treatment was also predictable because, as Volkow observes, fewer than 40 percent of addiction treatment facilities in the United States offer any of the three medications, while just 3 percent offer all three.
The Larochelle study found that, during the 12 months following the subjects’ overdoses, about 800 of the individuals died, including 368 who succumbed specifically to another opioid overdose. Mortality rates among those who started methadone or buprenorphine treatment after their overdoses were roughly half those of the people who didn’t. (The impact of naltrexone was unclear, because so few people used it.) Previous studies have shown that buprenorphine and methadone also improve patients’ social functioning, reduce drug-use related infections, and reduce criminal conduct.
Why isn’t it used more? In fairness, one intractable hurdle is the nature of the disease: the user’s intense, immediate craving for more opioids overwhelms and obscures the hard-to-remember allures of living clean.
A second issue is cost. It’s not cheap—about $5,500 per year—and some health insurers don’t want to pay for it. But that’s short-sighted (not to mention immoral), given that emergency department visits cost about $3,400 each while opioid-related hospital admissions approach $30,000 each, according to health economists Emily Gee and Richard Frank.
But the key enduring barrier is stigma. To be effective, these medications have to be taken long term—often for life. Since two of the three pharmaceuticals in question are themselves opioids (methadone and buprenorphine), many people have a hard time seeing them as medications rather than as a continuation of the problem. Just a year ago, then-Health and Human Services Secretary Tom Price—himself a physician—notoriously articulated this benighted view: “If we’re just substituting one opioid for another, we’re not moving the dial much.” (The is emphatically not a politically partisan issue, however. Just this week, for instance, Newt Gingrich penned an editorial in The Hill expressing at least as much frustration as Norkow at MAT’s maddening under utilization.)
While methadone and buprenorphine are opioids, they are opioids that do not require injection, can be administered once a day or less, do not cause euphoria at the correct dose, and permit resumption of a normal, productive life.
The superiority of medication-assisted therapy to those that aim for total opioid abstinence is so well documented that scientists regard further testing of the question as unethical. (The recent study was merely retrospective and observational, not a clinical test.)
In 2003—that is, 15 years ago—Swedish researchers published a clinical study in The Lancet comparing buprenorphine to a placebo pill as a means for treating heroin addiction, while providing each test group with behavioral therapy and drug counseling as well—the rough equivalent of most abstinence-oriented programs. (Heroin is an opioid, of course—stronger than, but not fundamentally different from, most prescription opioids.)
“This is the most lethal of all addictions, and the most lethal of all psychiatric disorders.”
Even back then, the Swedish researchers worried about the ethical issues inherent in depriving the control group of any medication, given that opioid addiction is a deadly disease and that methadone was already known to be an effective treatment. (Methadone has been used to treat opioid addiction in the US for more than 50 years.) But Swedish law at the time permitted only a small subset of heroin addicts to qualify for methadone—those who could produce hospital records proving at least four years of addiction—so the researchers populated their buprenorphine study entirely with people ineligible for methadone, i.e., people with no better alternative.
Of the 20 individuals randomly assigned to receive buprenorphine, 75 percent were still in therapy one year later, and 75 percent of their urine tests came back clean. Of the 20 assigned to the control group, treated only with behavioral therapy and counseling, zero were still in therapy one year later. They’d all relapsed and dropped out of the study.
In fact, they’d all relapsed and dropped out within the first two months of the study.
There’s one other noteworthy statistic that emerged from the Swedish study, though the researchers hadn’t originally planned to track it. At the end of the scheduled one-year clinical trial, 20 percent of the control group—the ones who didn’t get buprenorphine—were dead.
The lethality of opioid use disorder needs to be kept front and center in our minds, when we are tempted to indulge in magical, sentimental, or ideological thinking about how to treat it. When people are sent to detox or rehab centers, and do not follow up with medication-assisted therapy, they may be worse off than when they started. They have lost the tolerance they built up to opioids when they were using, but still have the cravings that will likely lead them to relapse. And when they do, and take doses they could once handle, they are vulnerable to overdose and death. (That’s why newly released prisoners are at shockingly increased risk for overdose death during their weeks of liberty.)
“This is the most lethal of all addictions, and the most lethal of all psychiatric disorders,” addiction psychiatrist Adam Bisaga, MD, told me recently. A professor at Columbia University’s medical school, Bisaga is the author of Overcoming Opioid Addiction, which came out in May.
And that was so before the arrival on our streets, beginning around 2013, of illicit fentanyl—at least 50 times more powerful than heroin. Fentanyl and other illegally trafficked synthetic opioids, mailed or FedEx-ed into the country from labs in China and elsewhere, are now often laced into heroin, counterfeit prescription opioids, and numerous other drugs, without warning to the user.
If and when the Trump Administration submits a National Drug Control Strategy—it was due in February—its centerpiece should be absolutely clear. We must educate the public on the proper treatment of this disease, insist that insurers pay for it, and incentivize doctors and clinics to provide it to all who seek it.
Some hospitals today try to lessen the pain of patients, especially children, by having them play virtual reality games during agonizing procedures.