Treating opioid addiction with other drugs is considered essential to helping Americans claw their way back from the throes of dependence.
Yet the estimated 2.1 million Americans addicted to opioids — more than 620,000 with heroin addiction — have difficulty getting the treatment they need.
Only 17.5 percent of those with addictions use one of the three medications approved by the Food and Drug Administration that help stop cravings and prevent opioids from working during relapses.
Overdose deaths from opioids have surpassed 400,000 since 1999. With addiction at an epidemic level, activists are working to shift public opinion away from the stigma that treatment amounts to trading one opioid for another, and lawmakers are giving more money to state programs to increase access to the treatments.
The federal Substance Abuse and Mental Health Services Administration in May announced $196 million in grants to expand medication-assisted treatment in states and territories that are hit hardest by the crisis.
“Ultimately, it’s clear there is an urgent need to ensure access to, and wider use and understanding of, approved treatments,” FDA Commissioner Scott Gottlieb said in April.
“Unfortunately, I believe that far too few people who are addicted to opioids are offered an adequate chance for treatment that uses medications.”
He also wants drugmakers to develop new treatments and to find a better way to determine whether an addict has been treated successfully.
“We must consider new ways to gauge success beyond simply whether a patient in recovery has stopped using opioids, such as reducing relapse overdoses and infectious disease transmission,” Dr. Gottlieb said in August. “Treatments that can impact these aspects of addiction can be important parts of a comprehensive approach to the treatment of opioid use disorder.”
The three drugs that have been used since the 1940s are methadone, buprenorphine and naltrexone. Below is a look at the medications and how they work.
Methadone is the oldest approved medication for opioid addiction yet one of the most stigmatized.
The drug itself has a high potential for addiction, so it is heavily regulated and allowed to be given only in government-licensed treatment centers. Only two states — North Dakota and Wyoming — don’t have methadone centers.
Methadone is an opioid agonist, meaning it works against opioid receptors in the brain. It’s an attractive option because it doesn’t require complete detoxification before it can be used.
Methadone works to reduce cravings for opiates, but it also cuts off the brain’s receptors. If a patient relapses, then the opioid can’t connect to the receptors, preventing the euphoric flood of dopamine and any stoppage of breath.
Methadone was researched after World War II as a pain reliever and substitute for morphine. American physicians discovered that it could be used to treat addiction.
But in the early 2000s, health officials were alerted to an increasing number of overdose deaths related to methadone. During the peak of the trend in 2006 and 2007, more than 10,000 deaths were reported. Researchers found that the spike was related to an increase in methadone prescriptions for pain, not as part of treatment programs. As pain prescriptions for methadone dropped, so did overdose deaths, down to 3,295 in 2017.
The Substance Abuse and Mental Health Services Administration has said using methadone to treat addiction is effective in higher doses, particularly for heroin users, and helps people stay in treatment longer.
“I think that the reputation of methadone clinics is worse … than how they actually work,” said Dr. Jeffrey T. Junig, who works in the clinics in Fond du Lac, Wisconsin.
“I was skeptical about it when I started a few years ago, but I really find it to be helpful for people these days.”
For the nearly 1.5 million people addicted to opioids, but not heroin, buprenorphine is a useful option for a more autonomous and discreet treatment plan.
Buprenorphine is a “partial agonist,” meaning it binds to opioid receptors in the brain but does not produce feelings of euphoria. People can get high from buprenorphine if they use large quantities and inject it intravenously.
When prescribed to treat opioid addiction, it is paired with the drug naloxone, the opioid overdose reversal medication, which works by blocking the receptors in the brain that promote shortness and stoppage of breath.
Patients can start treatment relatively quickly, although they have to be in a state of withdrawal or complete detoxification. The first few days and weeks require close observation to make sure the patient doesn’t relapse.
The advantage for patients is that it provides autonomy relatively quickly. It has a low potential for abuse, primarily because it includes naloxone.
Its benefits have prompted a surge in use. The percentage of people with addictions who were prescribed buprenorphine jumped to 8 percent in 2017 from less than 1 percent a decade earlier.
The magnitude of the opioid epidemic has pulled in physicians and medical providers who traditionally haven’t handled addiction treatment. About 46,500 health care professionals — including family doctors, physician assistants and nurse practitioners — now are certified prescribers. By law, first-year prescribers are allowed to treat up to 30 patients. That number expands to 100 and then 275 in subsequent years.
Barriers to getting more prescribers on board include access to funding, physician expertise and stigma.
In a survey of nearly 600 physicians, published in the Journal of Substance Abuse Treatment in 2017, researchers identified negative attitudes about prescribing buprenorphine on both a philosophical and practical level. Respondents said they were against the idea of trading one opioid for another, didn’t have enough time for the extra patient load and would be inadequately reimbursed for treatment.
But the respondents said they would be encouraged to prescribe buprenorphine if they were paired with experienced physicians, connected to local counseling resources and given continuing education on opioid addiction.
“What I’ve heard from physicians who have gone through the training … it’s adequate, but what they often find is it’s helpful to be mentored by physicians who are doing this work or who’ve done it for years,” said Dr. Mona Gahunia, associate medical director for primary care strategy for the Mid-Atlantic Permanente Medical Group, part of Kaiser Permanente. “That’s actually a key part in feeling comfortable prescribing buprenorphine.”
The least-used medication is naltrexone. Only about 23,000 people, or 2 percent of patients, used it in 2017.
The drug has shown to be effective in keeping people from using opioids and maintaining sobriety. Yet it is used less often than its counterparts because it requires complete detoxification.
Naltrexone operates in a different way from methadone and buprenorphine: It doesn’t activate opioid receptors in the brain. Instead, it binds and blocks those receptors to reduce opioid cravings. The FDA says there is no abuse or diversion potential with naltrexone.
In case of a relapse, naltrexone prevents the patient from getting high on a drug.
Also, unlike methadone and buprenorphine, naltrexone can be used to treat alcohol dependence.
Treating layers of addiction
Health care professionals have shifted their thinking on treatment to focus on a multilayered approach as the national conversation has moved from looking at addiction as a moral failing to a disease.
In May, the FDA approved the first non-opioid medication to treat withdrawal symptoms from opioids. The drug, lofexidine hydrochloride, is shown to lessen the severity of opioid withdrawal symptoms — including anxiety, agitation, sleep problems, muscle aches, runny nose, sweating, nausea, vomiting, diarrhea and drug cravings.
Many physicians who treat addicts say psychosocial support is key to maintaining sobriety, but it doesn’t have to be intensive. That has given physicians more options for treating patients without an immediate opening in a therapeutic treatment program.
“In order to have success with buprenorphine, you don’t necessarily need a very robust psychosocial support or an intensive psychosocial support, but you do need some,” said Dr. Ngozi Efobi, chief of the division of rehabilitation services and director of the pain management program at the Martinsburg VA Medical Center in West Virginia.
“Even doing something like a brief intervention is helpful, even patients attending [Alcoholics Anonymous] or [Narcotics Anonymous] is helpful, some brief psychosocial support is helpful,” he said.