Reconsidering drug treatment for opioid use disorder

Opioids relieve pain but are dangerous and highly addictive. In the last 12 months, there were 109,600 drug overdose deaths in the United States, 70% of which were opioid-related. In 2023, 5.7 million people ages 12 and older in the United States had opioid use disorder (OUD).

Despite the large number of opioid abusers in need of treatment, most please don’t Receive it. Some people don’t find it, some delay treatment, and some refuse treatment. By 2022, only about 25% of U.S. adults with OUD will medicine-Adjunctive treatment (MAT) such as methadone or buprenorphine.

Some people with OUD receive methadone at one of the 1,500 methadone maintenance treatment (MMT) clinics in the United States. Doctors. Vincent Dole and Marie Nyswander pioneered MMT and conceptualized OUD as a chronic metabolic disease in the mid-1960s. They argued that long-term medication is a necessary treatment for OUD, similar to insulin for type 1 diabetes. Researchers used Doll’s background in endocrinology and metabolism to theorize that OUD causes permanent changes in brain and body chemistry. They called this a “persistent disruption” of the opioid receptor system. They believe that this defect is the cause of intense and persistent cravings; recurrence Even after the addict has been detoxed from the drug.

They argued that addiction should be treated as a medical condition rather than an incurable character flaw. They found that methadone may stabilize “metabolic defects” by suppressing cravings and blocking the euphoric effects of other opioids, allowing individuals to function normally. In 1976, Doll and Nicewander addressed a common criticism that MMT merely replaced one opioid drug with another. They write that critics fail to consider “similar long-term use of other drugs such as insulin and digitalis in medical settings.” By proving that MMT can help former addicts return to school, get jobs, and reintegrate into society, their research provided a powerful rebuttal to moralistic views of addiction.

Methadone is a long-acting, orally administered opioid that does not produce the euphoria of other opioids, but it is safe and effective as a treatment for OUD and prevents withdrawal symptoms. Some experts (including myself) believe methadone should be available at local pharmacies in the same way addiction doctors prescribe buprenorphine.

After treatment

Even when buprenorphine or methadone is used for OUD, it is important to consider what will happen to people when treatment ends. Recently New England Medical Journal The paper is by A. Thomas McClellan, Ph.D., a professor at the University of Pennsylvania, and Nora D. Borkow, M.D., director of the National Institutes of Science. drug abuseproposed a patient-level “cascade of care” for OUD. the goal: Protection → Remission → Recovery.

McClellan and Borkow maintain that recovery is possible with continued drug treatment with methadone and buprenorphine. They argue that abstinence is neither necessary nor sufficient for recovery from OUD. They also argue that it is dangerous to abruptly stop medication treatment for reasons such as lack of progress.

The late Dr. Benji Primm, Dr. Herb Clever, and I have long agreed and advocated for widespread patient access to methadone and buprenorphine. I reviewed it in detail Successful methadone maintenance Since treatment began in the 1960s. Approximately 400,000 people are treated with methadone for OUD each year in the United States, but buprenorphine is more commonly prescribed.

The first goal after diagnosis or intervention is to focus on overdose prevention. This means drug treatment must begin as soon as an OUD diagnosis is made to prevent overdose and the risk of contracting HIV and other diseases from dirty needles used to inject drugs. Treatment with methadone or buprenorphine focuses on preventing overdose, preserving life, and continuing participation in the program.

Ideally, people with OUD are in remission from their addiction or have significant and sustained relief from their OUD symptoms. This result is likely due to daily MAT administration and the person receiving psychosocial rehabilitation support.

It’s important to understand that opioids cause changes in the brain do not have If you abstain, it will return to normal. The main problem occurs when people with OUD go out. off process. The risk of death from an overdose after detox is three to four times higher than if you continue taking buprenorphine or methadone. Just holding it has a strong protective effect. In contrast, the risk of relapse rapidly recovers after discontinuation of opioid medications, especially during the first month. In this case, tolerance to the drug has decreased so much that even previously low doses of the drug can kill the user.

Remission is possible within this system, with sustained and stable recovery possible after 12 months. Opioid use disorder, as opposed to cocaine, methamphetamine, cannabis, and even addiction, alcoholwe need to focus initial treatment to prevent overdose deaths above all else.

Why many people with OUD say “no” to MAT providers

Several factors limit access to medications to treat OUD. According to a CDC study, approximately 43% of adults seeking OUD treatment did not agree that OUD treatment was necessary. I think maintaining MMT is lifesaving, but they may see it as a continuation of chemical slavery. People may also choose buprenorphine because it is easier to stop taking than methadone. Physician and program preferences may also play a role.

The recent McClellan/Volkow NEJM article reminds us that Doll and Nicewander were right that there was (and still is) no way to reverse the effects of opioids on the brain. We ultimately reject time-limited detoxification for OUD as the primary treatment goal, and there is no need to discontinue medication due to incomplete progression. If necessary, patients should be referred to more intensive residential services.

Brian Ferline, M.D., of Yale University, points out that in emergency rooms, many patients are rescued with Narcan and discharged from the hospital, refusing other treatments. Physicians use this teachable moment to involve the patient, family, and other loved ones in the intervention and seek to initiate buprenorphine immediately. It is unclear what to do about treatment refusal or early dropout other than building trusting relationships and working together to reduce overdoses among people who are not ready for treatment.

conclusion

Doll and Niswander theorized in the 1960s that OUD is a chronic “metabolic disease” with permanent physiological changes. They concluded that abstinence was impractical due to continued metabolic deficiencies. Therefore, they advocated MMT as a long-term, often lifelong, treatment to stabilize this condition. There is no arbitrary deadline and treatment should be continued unless it is beneficial to the patient and opioid reduction is not required for recovery. We need to face reality and confront what opioid addicts experience and help them stay alive, adapt, and recover.

There is no treatment like penicillin for strep throat. Relapse is common, residual problems are often present, and treatment-resistant opioid use disorder has also been reported.