We have been treating people with opioid addictions for more than 30 years. It doesn’t make sense to us that, as the United States finally gears up to fight this epidemic, most clinicians are using the wrong approaches, like brief detox or being discharged to home or the street after a near-lethal overdose.
Proper treatment for opioid addiction substantially reduces overdoses and can markedly improve lives, and even save them. Yet most individuals with this brain disease aren’t getting any kind of treatment. And those who do get treated generally undergo detox — withdrawal from opioids and ultimately complete cessation of all opioid-related drugs. Not only does detox cause terrible withdrawal symptoms, but it doesn’t work for most people, and they start taking opioids again within days or weeks.
Natural receptors in the brain that respond to opioids are involved in many functions, from eating, breathing, and sleeping to pleasure and the perception of pain. Chronic use of opioids destabilizes these receptors, leading to physical, mental, and emotional dependence on the drug. Once the body’s opioid system is destabilized, it doesn’t heal easily. Several FDA-approved medications — notably buprenorphine, naltrexone, and methadone — can stabilize opioid receptors, helping the body and brain establish a “new normal.”
Without these medications, more than 90 percent of individuals with opioid addictions relapse within weeks or months of detox, all too often with serious or fatal consequences.
We strongly believe that wider use of these medications is an important component of easing the opioid epidemic. We aren’t alone. On Wednesday, FDA Commissioner Scott Gottlieb said that this approach, called medication-assisted therapy, “is one of the major pillars of the federal response to the opioid epidemic in this country.”
We have been using medication-assisted therapy at Harborview Medical Center since 2000. One of the first patients we treated with the combination of buprenorphine and naloxone was a young man who had been injured while working at a local steel processing plant. His primary care doctor prescribed an opioid. In addition to killing his pain, the man experienced what he called a “magical” effect — a powerful euphoria that kept calling him back to the drug. As is true for most people who become addicted to opioids, he kept needing more and more.
Eventually, his family became aware of his drug use, his doctor cut off his supply as he demanded higher and higher doses, and his health and function deteriorated. When his prescription ran out, he bought OxyContin and then oxycodone on the street. He finally came in for treatment, due to pressure from his family and the terrible withdrawal symptoms he was having when he couldn’t find drugs to buy.
His treatment consisted of a combination of buprenorphine and naloxone, which stabilized his opioid receptors, plus counseling and attendance at 12-step meetings. That was enough to help him get back to work. After staying on medication-assisted therapy for two years, he asked to stop. We tapered him off the two medications, and eventually stopped his regular visits to the clinic. He continued with 12-step meetings, and is still opioid free.
In the past, methadone clinics were the primary way to treat people with severe addictions to heroin, an illicit opioid that comes from the poppy plant. Methadone, a synthetically made opioid, fully occupies an individual’s opioid receptors, which stabilizes cravings for the drug. Methadone must be given daily, almost always in special clinics. While these clinics are effective, they are usually located in dense urban areas, less often in suburbs, and almost never in smaller cities, towns, or rural areas.
In the last 15 years, new FDA-approved medications have been developed to treat opioid addiction by stabilizing opioid receptors. These include the combination of buprenorphine and naloxone (brand name Suboxone) and naltrexone (brand name Vivitrol).
Buprenorphine/naloxone must be taken every day. Although it only partially blocks opioid receptors, it binds tightly to them and prevents most other opioids from latching on. This drug combination decreases cravings and prevents overdoses, even if an individual takes opioid pills or uses heroin. Naltrexone fully blocks opioid receptors; a single injection does this for a month.
Long-term therapy with these medications is essential. Once an opioid addiction is firmly established, it closely resembles type 1 diabetes — a lifelong condition in which something (insulin) is missing. That means most people with opioid addictions will need to be on long-term medication-assisted therapy, possibly for years, to kick their addictions.
Unlike methadone, buprenorphine/naloxone and naltrexone do not have to be distributed in special clinics. These medications make it possible to treat individuals with opioid addictions in virtually any primary care, mental health, or addiction clinic, whether it’s in a large city, a suburb, or a small rural town.
Despite the proven benefits of medication-assisted therapy, relatively few clinicians have gotten certified to dispense these medications. That requires completing an eight-hour training course. Among those who do get certified, half aren’t treating any patients for addiction.
Why don’t more physicians learn this skill? For one thing, they don’t get reimbursed for taking the course and getting certified. For another, there’s little support for physicians who deal with such a stigmatized and often-confounding condition as opioid addiction.
Helping physicians get certified would make it possible for more patients with opioid addictions to get the treatment they need. So would steps by our health care systems to develop and fund more support for clinicians and clinic managing these patients. There are many ways to do this. At our hospital, for example, state grants now support a nurse-care manager model, in which nurses play a larger role in managing medication-assisted therapy.
Our state Medicaid and health care authority have also pushed through better funding and fewer barriers for prescribing both buprenorphine/naloxone and naltrexone. Washington State also embarked on a large grant to expand opioid treatment into a variety of settings using a “hub” of addition-treatment experts working with “spokes” in communities that are developing services.
In Washington state, as in every other state in the Union, access to medication-assisted therapy must become a standard part of primary care — especially in rural areas where other addiction services often don’t exist.
Real, substantive challenges face us, but we now know what works clinically and have a roadmap for treating addiction — widespread provision of accessible and affordable medication-based treatment for the brain disease of opioid-use disorder.
Now what we need is for our public and private health care systems to establish this care more widely and enhance it with the support that both patients and their caregivers need.
Richard Ries, M.D., is professor of psychiatry and director of the University of Washington School of Medicine’s addictions division, and medical director of the Outpatient Addictions Program at Harborview Medical Center. He reports having received payments in 2014 from Alkermes, which makes naltrexone. Andrew J. Saxon, M.D., is professor of psychiatry at the University of Washington School of Medicine and director of the Center of Excellence in Substance Abuse Treatment and Education at the Seattle-Veterans Affairs Puget Sound Health Care System. He reports no conflicts of interest.