On Wednesday in West Virginia, President Obama gave one of his only speeches thus far in which he addressed the growing opioid epidemic in the U.S. The message he delivered was that providers across the country must begin expanding patient access to medication-assisted therapies (MAT) like buprenorphine and naloxone for treating opioid addicted patients. He goes on to suggest that providers who do not offer this treatment option, and instead choose to use only the abstinence model of treatment, are ignoring the large body of scientific evidence that supports MAT.
A few days prior to this announcement, he issued a corresponding federal order requiring all health care related federal agencies to identify MAT barriers and develop solutions to them within the next 90 days. Four weeks prior to that order, the Department of Health and Human Services announced that they would soon be loosening the current buprenorphine prescribing limit for DEA waivered physicians. What this translates to at the provider treatment level is that if a health care entity receives federal dollars, as do most treatment centers and drug courts, they may no longer bar MAT unless they they want to risk losing their federal funding.
Academically, this is a fascinating move. On the one hand, it addresses the rapidly growing problem around heroin overdose rates (and the high recidivism following abstinence based treatment for this disorder) while also considering the large number of therapeutic addiction cases we’re currently seeing in patients who were prescribed long-term, high-dose opioid therapy for pain by their physicians.
On the other hand, it suggests treating an opioid problem with another opioid, as many would claim. But is that true? Factually, buprenorphine is what’s called a partial opioid agonist meaning that it can eliminate opioid withdrawal and craving while not providing the euphoria associated with full opioid agonists like oxycodone. Additionally, by blocking the opioid receptors, it prevents potential overdose in patients that do slip and relapse on heroin or other opioid analgesics while on MAT.
These latest policy changes put some much needed spotlight on the rampant overdose and addiction rates in this country. For far too long, evidence has shown that addiction should be treated like any other chronic disease as it has very similar characteristics to diabetes and heart disease. Heritability, relapse rate, molecular changes, compliance, and outcome are all very similar among these various illnesses. Yet, addiction still has a significant stigma placed on it by society and the medical profession and these patients are not generally treated as others with a chronic illness would be.
While these are broad strokes being pushed down from the top, several questions still remain. Who are the best candidates for this therapy? How significant are the contributions of 12-step/abstinence treatment to the opioid epidemic? When should therapy be discontinued? Does other drug use during therapy negate the benefits of MAT?