With more than 27 million people suffering from substance use disorders, the opioid crisis is a global health problem. In 2016, for example, 275 million people admitted to taking drugs (34 million used opioids, while 19 million took opiates).
Note that although the terms opiates and opioids are often used interchangeably, there’s a subtle difference: opioids refer to all drugs that affect the opioid receptors in the human brain. Opioids can be semi-synthetic (e.g., hydrocodone) and synthetic (e.g., fentanyl). Opiates, on the other hand, are opioids that are naturally derived from the opium poppy plant (e.g., codeine). Opioids can be divided according to their potency and pharmacological effects: agonists (e.g., morphine), partial agonists (e.g., buprenorphine), agonists-antagonists (e.g., nalorphine), and pure antagonists (e.g., naloxone) (Trivedi, Shaikh & Gwinnut, 2007).Info 1: Opiates vs. Opioids
Evidence shows that taking opioids for a long time leads to physical dependence and symptoms of tolerance and withdrawal. However, substance use does not always result in addiction; addiction is characterized by psychological dependence and compulsive substance abuse despite harmful consequences.
Although drug addiction is often associated with illicit drugs, such as heroin, prescription opioids are among the most misused substances across the globe. In the US, more than two million people started using opioids in 2017. Additionally, according to data provided by the Centers for Disease Control and Prevention, opioids accounted for 67.8% of all 70,237 drug overdose deaths in America in 2017. In Australia, prescription opioids are the leading cause of premature death in two-thirds of all drug-related fatalities. According to the United Nations Office on Drugs and Crime, the highest rates of prescription abuse in Europe are across Northern Ireland, Denmark, Germany, Estonia, and Finland, while the highest mortality rates are in Ukraine, Ireland, Iceland, and Luxembourg.The prescription opioid crisis in the US, in particular, has reached pandemic levels. The US accounts for 5% of the global population and 80% of the global opioid supply. Every year doctors issue approximately 200,000,000 opioid prescriptions; consequently, the sale of painkillers across the States has increased by 300% since 1999.
Data shows that 20-30% of people who use prescription drugs misuse them, 8-12% become addicted, and 4-6% of all people with an opioid use disorder will take heroin. Moreover, between 2002 and 2011, more than 25 million Americans started nonmedical use of prescription pain killers. In 2015, there were more than 91.8 million people who used prescription opioids and out of them, 11 million misused the drugs (Huecker, Azadfard & Leaming, 2019).
Today, more than 2.1 million people in the US are living with an opioid use disorder. Alarmingly, 130 people die from an opioid overdose every day. In fact, opioid overdoses increased by 30% from July 2016 to September 2017 in 45 states. The Midwestern region, in particular, saw an opioid overdoses increase of 70% during this period.Info 2: The Drug Epidemic in the US
While there are effective medication-assisted treatments for opioid addiction, data shows that only 10% of users receive adequate care. Of all residential programs, only 36% offered medication-assisted treatment in 2016. So, why are effective medication-assisted treatments limited and treated as a further cause of addiction?Medication-assisted treatment (MAT) is defined as a combination of medications and behavioral therapies for the treatment of drug addiction in safe settings. Globally, medication-assisted treatments are the gold standard in opioid addiction care. Medication-assisted therapies prove to be highly effective methods, with methadone, buprenorphine, and naltrexone being the three FDA-approved medications for opioid use disorder (Medication-Assisted Treatment for Opioid Use Disorder, 2018). Evidence shows that medication-assisted treatments lead to a variety of physiological, mental, social, and financial benefits. For example, medication-assisted treatments result in reductions in factors, such as morbidity and mortality rates, overdose deaths, infectious diseases, treatment dropout rates, and criminal activity. Interestingly, demographics have shifted significantly; while in the 1960s, 80% of patients entering treatment were men, living in inner-city areas and using heroin, by 2010, the majority of patients were middle-class women living in less urban areas.
- Methadone: Methadone is a potent opioid agonist. Evidence shows that methadone is efficacious in treating addictions and has high retention rates. The drug blocks the pleasurable experiences produced by other opioids and reveals the highest analgesic potential. Moreover, methadone has both slow onset and offset, which decreases the prevalence of withdrawal symptoms and cravings. Initially introduced in treatment in 1964, methadone is now widely used in approved Opioid Treatment Programs and accepted as first and foremost effective medication, which reduces drug-related morbidity and mortality rates. Note that the Opioid Treatment Programs in the US are regulated by the Substance Abuse and Mental Health Services Administration (SAMHSA). Data shows that between 2003 and 2015, the number of clients receiving methadone increased from about 227,000 to 350,000. Although methadone is an effective evidence-based treatment, the drug is still highly stigmatized, and patients lack access to treatment or take-home dosing privileges.
- Buprenorphine: Buprenorphine is a partial agonist and a Schedule III controlled substance with a terminal half-life of three-four hours and duration of action of up to eight hours. The main benefit of buprenorphine is that the medication can be used in office-based settings. In fact, the number of Opioid Treatment Programs offering buprenorphine increased from 11% to 58% between 2003 and 2015, while the number of clinics without Opioid Treatment Programs offering buprenorphine increased from 5% to 21% for the same period. As of 2013, data shows that the medication has the largest coverage across state Medicaid programs. Buprenorphine is available in a stand-alone formulation or in combination with naloxone. Note that Suboxone is the common name for the combination of buprenorphine and naloxone in a 4:1 ratio. Despite its evidence-based benefits, buprenorphine also sparks controversy and is subjected to numerous Medicaid limitations. Factors, such as buprenorphine prescribing waiver and prior authorization criteria, also become major barriers to its successful implementation in opioid addiction treatment.
- Naltrexone: Naltrexone is an opioid antagonist medication used to treat opioid addiction, as well as compulsive eating disorders. Note that unlike methadone and buprenorphine, naltrexone requires a period of opioid withdrawal before initiation. Naltrexone is available in both oral and injectable formulations, with injectable naltrexone being more effective than oral naltrexone (Sullivan et al., 2018). The number of Opioid Treatment Programs and other facilities offering naltrexone doubled between 2011 and 2015. Yet, medication-assisted treatment with naltrexone is highly restricted.
Info 3: Medication-assisted Treatment: The Gold Standard in Opioid Addiction CareInfo 4: Myths about Medication-assisted treatment
- Myth: All medications lead to substance misuse
Although medication-assisted treatment is the gold standard around the world, many opponents claim that medication-assisted treatment consists of replacing one drug with another. While it’s true that methadone, buprenorphine, and naltrexone are potent substances, using medications does not always lead to addiction. Being physically dependent does not qualify for a substance use disorder. In fact, the majority of products people use daily, such as sugar, tobacco, and caffeine, can cause dependence. As stated earlier, under the Diagnostic and Statistical Manual of Mental Disorders, addiction consists of the compulsive misuse of a substance despite its consequences, including committing crimes and overdosing. Medication-assisted treatment, on the other hand, helps people cure their addiction and take their medication in a regulated and safe environment in order to become functioning members of society. In particular, buprenorphine can be used in office-based settings and help patients rehabilitate their daily and social activities.
- Myth: Medication-assisted treatment is not effective
Another criticism is that medication-based treatments do not work for around 40% of users. Opponents claim that some patients prefer total abstinence, while others do not respond well to their medications. However, this is not a valuable scientific point because in medicine; patients always respond differently to treatments (e.g., chemotherapy), and some people need alternative therapies. People with a substance use disorder, for example, might need cognitive behavioral therapy or group support (e.g., 12-step program) to fight their addiction. Some patients may even need prescription heroin to begin their journey to sobriety. Nevertheless, evidence shows that medication-assisted treatment is the gold standard in practice. Buprenorphine, in particular, reveals numerous benefits in opioid replacement treatment and has the potential to fight opioid overdosing.
- Myth: Abstinence is safer
Myths regarding the dangers of medication-assisted treatment have deadly consequences. Both the health care and criminal justice systems in the US treat patients like criminals and deprive people (e.g., incarcerated patients) from life-saving medications, which often results in overdose deaths. Administrative restrictions also impose barriers; waiting periods, skyrocketing costs, limited geographical coverage, and governmental rules often limit people from accessing care. To provide an example, the federal government still caps the number of patients doctors can prescribe buprenorphine to. Note that to integrate treatment in general medical settings, the Drug Addiction Treatment Act of 2000 (DATA 2000) was introduced in practice. DATA 2000 permits qualified physicians to request a waiver from the Controlled Substances Act to treat patients outside of an Opioid Treatment Program. Interestingly, two buprenorphine formulations were approved as the first products under DATA 2000. While governmental limitations still exist, provider barriers and bias also impact opioid replacement therapies. Some providers with a waiver underuse buprenorphine or show low confidence in addressing addiction and reimbursement concerns. In fact, only 44-66% of DATA-waived physicians prescribe buprenorphine, and the majority of them do not prescribe to their maximum limit (Jones et al., 2015).
- Myth: Addicts choose to be addicts
Perhaps the worst barrier is the stigma that marks substance misuse, which is unthinkable in other chronic conditions. Addiction is a complex problem, and while normal choices can lead to addiction, nobody chooses to become addicted. As stated earlier, many products people take can be addictive. Nevertheless, the majority of people and lawmakers fight the disease model of addiction. Consequently, health experts often underestimate evidence-based treatments, and two-thirds of courts restrict medication-assisted care, leaving incarcerated people without life-saving medications. Hostile language worsens the problem, and the strong public bias often affects insurance policies and patients’ choices.Despite the public bias and stigma that marks opioid addiction, medical professionals across the world insist that medication-assisted treatment is the gold standard in treatment. Evidence shows that opioid replacement medications result in numerous benefits across settings:
- Decreasing opioid use prevalence in pregnancy: Opioid abuse among pregnant women is an alarming social problem. Data shows that between 2008 and 2012, 39.4% of Medicaid insured and 27.7% of privately insured women of reproductive age filled an outpatient prescription for an opioid drug. Additionally, one in five pregnant women filled a prescription for an opioid, and 2.5% received a chronic opioid prescription for more than 30 days. Consequently, from 2000 to 2012, the number of infants diagnosed with neonatal abstinence syndrome grew five times larger (Krans & Patrick, 2016). From 1992 to 2012, the number of pregnant women admitted to substance abuse treatment facilities increased from 2% to 28%. Due to the inadequate and discriminatory policies in the US, however, substance abuse during pregnancy can be classified as criminal child abuse or assault, which criminalizes women and prevents patients from accessing care. Note that evidence shows that detoxing during pregnancy can be fatal, so access to medication-assisted treatment can only improve health outcomes for mothers and their children.
- Improving the outcomes for chronic pain patients: Pain – “the fifth vital sign” – can be disabling. Data shows that in the US alone, more than 30% of people suffer from acute or chronic pain, and more than 40% of older adults suffer from chronic pain. In 2012, more than 259 million prescriptions for opioid pain relievers were issued (Volkow & McLellan, 2016). However, due to various pharmaceutical marketing practices and stricter regulations, a huge percentage of primary clinics refuse to take new pain patients and chronic pain patients are left disabled. By helping addicted individuals access Opioid Treatment Program facilities, governmental bodies will target substance misuse effectively and stop treating chronic pain patients like criminals.
- Reducing overdose and death rates: In the US alone, more than 130 people die after overdosing, making opioid addiction a national crisis and opioid overdose a leading cause of premature death. A study following 122,885 people on methadone over 1.3-13.9 years and 15,831 people on buprenorphine over 1.1-4.5 years showed that medication-assisted treatment led to reductions in overdose mortality and morbidity rates (Sordo et al., 2017). Note that naloxone is used to prevent opioid overdose deaths and restore normal respiration.
- Limiting HIV and infectious outbreaks among addicted individuals: The connection between drug use and HIV infections is evident (Bruce, 2018). Unfortunately, bias and discrimination still limit people with substance use disorders and their families from accessing treatment for HIV, hepatitis C, and tuberculosis. Data shows that medication-assisted treatment can reduce injection-related HIV risks and improve access to antiretroviral therapy and health status. A study showed that HIV antibody conversion occurred within 18 months in 22% of 103 out-of-treatment heroin users, compared to 3.5% of 152 people receiving methadone.
- Data indicate that opioid substitution treatment can successfully reduce rates of HIV transmission and that patients receiving such treatment can adhere to therapies for HIV, hepatitis C, and tuberculosis infection. Integration of opioid substitution treatment into the HIV clinic setting can make such treatment easier and improve retention in treatment. This article summarizes a presentation by R. Douglas Bruce, MD, MA, MS, at the IAS–USA continuing education program held in Chicago, Illinois, on May 2018.Keywords: Opioids, addiction, HIV, methadone, buprenorphine, naloxoneReducing homelessness: In the US alone, homelessness is a growing problem. In 2007, more than 671,888 individuals were homeless, 38% had problems with alcohol, 46% with drugs, and 45% with mental health issues (Kertsez et al., 2009). Alarmingly, surveys show that people on methadone or other opioid replacement medications can be denied housing or other services, such as sober living environments. By erasing the stigma, which marks addiction and improving opioid treatment regulations, the percentage of homeless people with a substance use disorder will decrease. Ending homelessness can positively impact societies; it can reduce the costs associated with admissions to crisis centers and improve the outcomes for young people.
- Decreasing annual health-related costs: Medication-assisted treatment can lead to reductions in costs imposed on society. Note that costs associated with untreated opioid addictions (e.g., criminal justice, injuries due to intoxication, lost productivity) reached $78 billion in 2013, with only 3.6% invested in treatment. Treating newborns with drug withdrawal, for instance, accounts for $1.5 billion in health expenditures. Opioid replacement treatment costs, on the other hand, do not exceed the costs of other health conditions. Methadone treatment and related services reach $6,552 per year, buprenorphine and medication visits make $5,980 per year, naltrexone treatment and related administrative services hit $14,112 per year. In comparison, the annual costs for people with kidney disease are approximately $5,624. The stigma around opioid addiction, however, makes the integration of medication-assisted treatment in practice ponderous.
Info 5: Benefits of Medication-assisted TreatmentOpioid use disorder is a global health problem, with more than 27 million people around the globe who suffer from substance use disorders. In the US, in particular, prescribed opioids are among the most misused substances, which result in adverse health and social outcomes as well as premature death. As stated above, the US accounts for 5% of the global population but 80% of the global opioid supply. Note that the opioid crisis in the US is killing more people compared to car accidents and HIV/AIDS. To be more precise, approximately 130 people die from an opioid overdose every day.
To address the opioid epidemic worldwide, medication-assisted therapies have been accepted as a gold standard in addiction treatment; with methadone, buprenorphine, and naltrexone being the three FDA-approved opioid replacement medications in the US. Evidence shows that medication-based treatments can reduce homelessness, criminality, financial burden, and infectious outbreaks. Social stigma, discriminatory insurance policies, and ineffective regulations, however, often stop patients from accessing life-saving treatment. Consequently, many incarcerated people, pregnant women, and even chronic pain patients are severely affected by punitive drug policies and treated like criminals.
Instead of penalizing people with opioid misuse disorders, regulatory bodies and health providers should invest in medication-assisted treatments and focus on: a) improving geographical coverage and insurance policies; b) loosening strict requirements and admission criteria; c) allowing incarcerated people and pregnant women to continue treatment; d) investing in research and related health services. Moreover, lawmakers and health providers should tackle the stigma that marks opioid addiction and helps patients become functioning members of society.Info 6: The Way to Recovery
To sum up, research shows that medication-assisted treatment is the gold standard of care in opioid addiction treatment and scientific evidence further proves that replacement substances like buprenorphine can save lives and improve economies. In a world where the opioid crisis is reaching pandemic levels, the expansion of evidence-based care and medication-assisted treatment is more important than ever because opioid replacement medications are a cure, not a cause of addiction.
- Bruce, R. (2018). Opioid Addiction, Opioid Addiction Treatment, and HIV Infection. Topics in Antiviral Medicine, 26(3), p. 89-92.
- Huecker, M., Azadfard, M., & Leaming, J. (2019). Opioid Addiction. StatPearls Publishing LLC.
- Jones, C., Campopiano, M., Baldwin, G., & Katz, E. (2015). National and State Treatment Need and Capacity for Opioid Agonist Medication-Assisted Treatment. American Journal of Public Health, 105(8), p. 55-63.
- Kertesz, S., Crouch, K., Milby, J., Cusimano, R., & Schumacher, J. (2009). Housing First for Homeless Persons with Active Addiction: Are We Overreaching? Milbank Q, 87(2), p. 495-534.
- Krans, E., & Patrick, S. (2017). Opioid Use Disorder in Pregnancy: Health Policy and Practice in the Midst of an Epidemic. Obstetrics & Gynecology, 128(1), p. 4-10.
- National Academies of Sciences, Engineering, and Medicine (2018). Medication-Assisted Treatment for Opioid Use Disorder: Proceedings of a workshop – in brief. Washington, DC: The National Academies Press.
- Kochanek, K., Murphy, S., Xu, J., & Aria, E. (2017). NCHS Data Brief. No. 293
- Sordo, L., Barrio, G., Bravo, M., et al. (2017). Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ.
- Sullivan, M., Mannelli, P., Yu, M., Nangia, N., Graham, C., Webster, I., Tompkins, D., Kosten, T. Akerman, S., Silverman, B. (2018). Outpatient transition to extended-release naltrexone in patients with opioid-use disorder. American Journal on Addictions, 27(4).
- McCance-Katz (2017). The National Survey on Drug Use and Health: 2017
- Trivedi, M., Shaikh, S., & Gwinnut, C. (2007). Pharmacology of opioids.
- Volkow, N., & McLellan, T. (2016). Opioid Abuse in Chronic Pain — Misconceptions and Mitigation Strategies. The New England Journal of Medicine.