Researchers say there are too many gaps between current treatment options for opioid drug abuse and the evidence-based practices utilized in much of the rest of the developed world. Photo by flickr user ep_jhu.
Just behind car accidents, opioid drug overdoses now rank as the second leading cause of accidental death in the United States. They’re so frequent they qualify as an epidemic, public health officials say.
As of 2009, around 2.3 million Americans suffered from addiction to opioids such as heroin or the prescription drug oxycodone. And according to new research, many of them aren’t getting the help they need.
In an article published Monday in the journal Health Affairs, Dr. Bohdan Nosyk and seven other experts in the field say there’s a major gap between current treatment options and evidence-based practices.
“Forty-five years after the introduction of opioid substitution treatment, practitioners have at their disposal more tools than ever to treat opioid dependence,” the researchers wrote. “Yet these tools are not being used to their greatest potential in the United States or Canada.”
Nosyk — an associate professor of health economics in the Faculty of Health Sciences at Simon Fraser University in Burnaby, British Columbia — said excessive regulation presents the biggest barrier for treatment in the U.S.
He spoke to the PBS NewsHour recently about the current state of opioid addiction treatment, options for closing some of the existing gaps and how the Affordable Care Act might play a role.
PBS NEWSHOUR: Dr. Nosyk, thank you so much for joining us. Let’s start broadly. Tell us about some of the different methods for opioid addiction treatment that exist today.
DR. BOHDAN NOSYK: There are really two dominant methods of treatment, and they’re based on opposing philosophies: On the one hand, we have short-term detoxification, which is typically scheduled beforehand to last from three to 12 weeks and is focused on achieving abstinence from opioids.
On the other, we have maintenance treatment, which lasts indefinitely and is focused on reducing the individual and social harms associated with opioid abuse, such as the risk of detox death, criminal activity, and subsequent HIV and Hepatitis C infection.
Maintenance treatment with methadone is the dominant form of treatment for opioid dependence throughout most of the developed world. However, detox is still a popular option, particularly in the U.S.
That said, we’ve known for decades that detox is ineffective in getting, and keeping people off of opioids. This is true even in youths who don’t inject and had relatively little experience with opioids before entering treatment. What we’ve learned in recent years is that addicts are at highest risk of death in the first two weeks of treatment, and in the two weeks following discontinuation of treatment. That means a three-week detox regimen exposes addicts to an extremely high risk of death for four out of five consecutive weeks. So, aside from being ineffective, it’s extremely dangerous.
Click the graphic below for a breakdown of treatment options in the U.S. and Canada:
PBS NEWSHOUR: Why is the detox method used so frequently in the U.S.?
DR. BOHDAN NOSYK: Detox is attractive to the public and also many clients, who would like to see a definitive end to their addiction. Unfortunately, more often than not, it just doesn’t happen that way. Opioid addiction is a chronic, recurrent disease. Those who manage to survive it tend to cycle in and out of treatment, regularly relapsing back to illicit use.
Now what we’ve learned in the various longitudinal studies that have been done is that, over time, periods of treatment and abstinence — if they’re attained — tend to get longer, while periods of relapse tend to get shorter. That’s really the best way to characterize recovery from opioid dependence, and it absolutely requires long-term access to treatment.
PBS NEWSHOUR: From your perspective, what are the major barriers to this kind of treatment?
DR. BOHDAN NOSYK: Structurally, I think the biggest barrier to treatment in the U.S. is the excessive amount of regulation involved.
Unlike most of the rest of the developed world, methadone is only available in specialized drug treatment centers in the U.S. They’re regulated by the Drug Enforcement Administration, the Substance Abuse and Mental Health Services Administration and it’s not available in regular physicians’ offices. So these regulations were put into place to prevent methadone from being diverted. In other words, they weren’t conceived with the patients’ best interests in mind, but rather a concern, justified or not, for public safety.
In the meantime we’ve seen a dramatic increase in the illicit use of other medically-prescribed opioids — oxycontin, vicodin and percocet, among others, which are much more attractive street drugs than methadone.
Because it is less likely to be diverted, Buprenorphine was allowed to be prescribed in physicians’ offices in 2003, and it is thought that over 140,000 Americans now access buprenorphine in this way. Methadone is a more effective, and considerably cheaper medication, and may therefore provide better value for money while further expanding access to treatment.
PBS NEWSHOUR: The study stresses the importance of office-based treatment. Can you explain what that means and why it’s significant?
DR. BOHDAN NOSYK: Office-based treatment is simply making opioid substitution treatment available from general practitioners, with the medication being dispensed through community pharmacies. That’s how it’s done in Canada and that’s how it’s done in most of the developed world.
However, it’s really about treating opioid dependence like the medical condition that it is. Aside from increasing access to drug treatment, I think there are other benefits as well. Substance abuse is very often associated with mental health conditions and drug injectors have high rates of HIV and Hepatitis C. Treating these clients in office-based settings provides an opportunity for more comprehensive medical care for the most difficult cases.
PBS NEWSHOUR: Coverage for many Americans will be changing in the coming months as the bulk of the Affordable Care Act takes effect. How will that play into all of this?
DR. BOHDAN NOSYK: Within states that adopt the Affordable Care Act, there will be an immediate benefit to the uninsured who perhaps couldn’t afford to access treatment in the past, so that will help.
However, this isn’t going to come cheaply. Allowing drug treatment in office-based settings, and, critically, training the physician workforce in addiction medicine, I think are the keys.
Massive increases in access to opioid substitution treatment were witnessed in Canada after we deregulated in 1996. The Affordable Care Act provides an opportunity and a stimulus, for efficient and effective policy change.
PBS NEWSHOUR: Are we seeing any other shifts in the way opioid addiction is treated or viewed in the U.S.?
DR. BOHDAN NOSYK: It’s funny, opioid substitution treatment was initially conceived in the mid-’60s as a long-term treatment option, but was soon restricted at the onset of the so-called “War on Drugs” in the early ’70s.
Slowly, I think we’re seeing the pendulum swing back towards evidence-based treatment, which I’d say is attributable to the volume and level of scientific evidence that’s been produced, as well as, perhaps, changing public perceptions about the nature of addiction, and how best to respond to the social problems created by drugs.
PBS NEWSHOUR: Let’s close with a segment of the population you say is at particular risk: Prison inmates. What do you see as the problem there?
DR. BOHDAN NOSYK: A recent survey of state prison systems in the U.S. found that just over half reported offering methadone to inmates in very limited situations — often exclusively for pregnant women or chronic pain management, and referrals to treatment after release are even less common. So very few opioid addicts that actually enter the prison system are actually getting treated.
The results of this survey showed it came to beliefs and ideology: Most survey respondents, who were wardens and other prison representatives, were not informed of the benefits of opioid substitution treatment, and preferred drug-free detoxification instead.
The good news is that now there’s some really good research coming out on this topic from the Center for AIDS Research – Collaboration on HIV in Corrections. So the authors of this study estimated that some 200,000 individuals with heroin addiction pass through American correctional facilities every year. So that’s staggering. You think of the volume of those problems.
The prison system has to be viewed as a rare contact point to treat substance abuse as well as HIV and Hepatitis C for individuals who are typically difficult to reach. This is especially important in the context of containing the spread of HIV/AIDS given the preventative benefits of antiretroviral treatment. Testing and treatment of addiction and infectious diseases has to become a priority moving forward.
PBS NEWSHOUR: Dr. Nosyk, thank you so much for joining us.
DR. BOHDAN NOSYK: Thank you.
This interview has been lightly edited for clarity.