Strong evidence exists on how to treat opioid-use disorder. The challenge is getting payers and policymakers to understand it so that physicians and other health professionals are better able to follow it, according to one expert who has implemented a successful, evidence-based program at her institution.
“We spent many decades trying to punish people into getting well,” said Sarah E. Wakeman, MD, medical director of the Substance Use Disorders Initiative at Massachusetts General Hospital (MGH).
That approach simply has not worked.
Opioid-related inpatient stays rose 641 percent from a rate of 136.8 per 100,000 people in 2005 to 224.6 in 2014, according to a December 2016 statistical brief published by the Agency for Healthcare Research and Quality. Similarly, a 99 percent increase was seen in the number of opioid-related emergency-department visits, going from 89.1 per 100,000 people in 2005 to 177.7 in 2014.
And according to the most recent data from the Centers for Disease Control and Prevention, overdose deaths involving opioids have quadrupled since 1999. The drugs are part of an epidemic that kills hundreds of Americans each day, the CDC says.
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“Patients deserve compassion and evidence-based care for the treatment of substance-use disorders,” said Patrice A. Harris, MD, chair of the AMA Opioid Task Force. “We must continue to work with payers and all stakeholders to remove barriers to care, which range from administrative barriers imposed by some payers to the stigma often associated with receiving treatment.”
Along these lines, the President's Commission on Combating Drug Addiction and the Opioid Crisis today issued its final report draft.
In a statement, Dr. Harris commended the commission for "delivering a comprehensive report that provides an excellent roadmap for increasing access to medication-assisted treatment for patients with substance-use disorders and also demonstrates the need to eliminate barriers to accessing the full spectrum of multidisciplinary pain treatment options." The commission agreed with many of the AMA's suggestions to tackle the opioid epidemic.
"We look forward to working with the administration and Congress on next steps, including the needed financial resources," Dr. Harris added.
The approach that saves lives
For Dr. Wakeman, a key is to recognize substance-use disorder as a chronic disease and treat it accordingly.
“Treatment takes time,” she added.
The goal with substance-use disorder should be the same as the goal for diabetes—management of the disease without the expectation of a cure, Dr. Wakeman said.
Effective treatment, “first and foremost,” includes pharmacotherapy with methadone, buprenorphine or naltrexone forming the “cornerstone of treatment.” Mortality goes down with pharmacotherapy, particularly with methadone and buprenorphine.
“These medications are truly life-saving,” Dr. Wakeman said.
Pharmacotherapy can be combined with psycho-social interventions and recovery support, which can include recovery coaches who are nonclinical peers going through recovery themselves.
What the evidence shows to be ineffective is acute, short-term detoxification treatment, yet it appears to persist as a treatment of choice.
“Detoxification alone is really not treatment,” Dr. Wakeman said. “The public has not gotten the message.”
One of the strongest pieces of evidence on this is 14 years old. In a study published by The Lancet in 2003, Swedish researchers randomly gave either a placebo or buprenorphine in combination with “intensive psychosocial therapy for heroin dependence.”
The one-year retention-in-treatment rate was 75 percent for the buprenorphine group and 0 percent with those who took a placebo.
“The combination of buprenorphine and intensive psychosocial treatment is safe and highly efficacious, and should be added to the treatment options available for individuals who are dependent on heroin,” the researchers concluded.
Yet the science has yet to firmly take hold, in part because society has spent a century “criminalizing addiction,” Dr. Wakeman said. In addition to the continuing stigma attached to substance-use disorder, she added that some still discount medication-assisted treatment as “replacement addiction.”
The end result of this thinking is that “we make patients work really hard for medications,” she said.
Assessment uncovers growing need
At Massachusetts General, the evolution of treating the acute medical complications of substance use to managing substance-use disorder as a chronic disease was spurred by a 2012 needs assessment that identified substance use as the top health concern. This led to the 2014 launch of Substance Use Disorders Initiative that Dr. Wakeman leads.
The effort includes, Dr. Wakeman said, a multidisciplinary inpatient substance-use disorder consult team that provides comprehensive evaluation and treatment recommendations in the same way they are offered by other departments, such as cardiology.
“We know we’re not going to get someone well in a four- to five-day hospital stay,” she said. The goal is to use hospitalization as an opportunity for engagement and treatment initiation.
Transitional care is offered to discharged inpatients and patients leaving the emergency department at the Bridge Clinic. Dr. Wakeman noted that ED patients are walked to that clinic, which is in the same building, and can receive a buprenorphine prescription.
Recovery coaches, who are the patients’ nonclinical peers, are embedded in the primary care team and help patients navigate the health care system and give motivational support, according to the MGH website.
Though the program has shown early successes and has established an addiction medicine fellowship, Dr. Wakeman is focused on continued growth and improvement.
“We still have a ton of work to do,” she said.
Dr. Wakeman was the presenter for an AMA webinar, “Addressing the Opioid Crisis Through Treatment of Opioid Use Disorder: The Physician’s Role.” The webinar was not archived, but Dr. Wakeman’s presentation will be used in the development of AMA CME materials.
Online CME, such as “A Primer on the Opioid Morbidity and Mortality Crisis: What Every Prescriber Should Know,” can be found along with other resources on the AMA Reversing the Opioid Epidemic microsite.
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