Opioid dependence is growing at an alarming rate in the U.S. We lose 78 people to opioid-related overdoses each day. Many groups face the repercussions of this epidemic—policy makers, law enforcement, educators, public services, families, and more. But healthcare providers face the consequences of opioid addiction daily in their medical practices.
This puts many specialists who didn’t set out to practice addiction medicine on the frontlines of addiction treatment. Neurologists, for example, may find addiction to be an ever-growing concern in their practices as they care for patients dealing with nerve pain. It’s a spot that may be unfamiliar to many. To those who are more familiar with addiction medicine, solutions are in short supply. A lack of evidence and resources stands in the way of adequate treatment options.
E Peles and colleagues identified one such gap in the evidence. In 2013, they published a study of their own patients after their methadone maintenance treatment (MMT) clinic reached capacity. As reported in the Journal of Addiction Medicine, patients had to wait more than a year for treatment. The mortality rate for those who had to wait for admission to treatment was ten times that of those who were admitted. That is alarming when you consider that less than half of the 2.2 million individuals in the U.S. who need MMT are receiving it.
But the wheels of change move slowly, and many people will die of overdose long before access to MMT expands to meet the need. But buprenorphine has been on the scene as an alternative solution for years.
As background, buprenorphine was approved for the treatment of opioid addiction in 2002, and physicians have been encouraged to prescribe it since then. In a letter to the editor published in December 2016 in the New England Journal of Medicine, researchers shared trial results that demonstrate the wisdom of this recommendation.
In the study, 50 patients who were on waiting lists for admission to MMT were randomized to receive buprenorphine or no treatment at all while they waited. Eighty-eight percent, 84 percent and 68 percent of those who received buprenorphine had negative urine tests for opioids at 4, 8 and 12 weeks respectively. Of the subjects who received no treatment, all urine samples were positive for opioids.
A response letter published in March pointed out potential pitfalls in the study, including lack of a placebo group and the increased interaction between researchers and the treatment group. The original authors offered a reassuring response, but it is clear that with such a small study more research is needed to identify the specific interim protocol that will yield the greatest benefit.
But for the physician on the front line, this research offers incentive to respond to the epidemic in a more systematic way. This may include a number of strategies, including reducing the stigma associated with addiction, promoting safe storage of opioids among pain patients, as well as gaining certification to prescribe buprenorphine. Barriers to certification are not small, but a sweeping change that will render the opioid epidemic a thing of the past is unlikely.
As Michael Botticelli, former White House drug czar explained it, “It’s a national crisis that manifests itself as a local problem. Local problems require local solutions.” This means change has to happen one patient—and one doctor—at a time.