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Op-Ed: The Wrong Way to Treat Opioid Addiction

Before Joe Thompson switched treatments for his opioid addiction, he was a devoted stay-at-home father, caring for his infant son after his wife returned to work. His recovery was aided by the anticraving medication buprenorphine. But after over two years free of heroin, Mr. Thompson, a former United Parcel Service worker from Iowa, relapsed and decided to try another kind of treatment program…

By Maia Szalavitz

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US needs to invest ‘tens of billions or hundreds of billions’ to fight opioid epidemic

The goal of an opioid is to reduce pain, but the addictive drugs are creating pain for millions of families suffering through the crisis.

Deaths from opioid overdoses number at least 42,000 a year in the U.S., according to the Center for Disease Control.

“This is an epidemic that’s been getting worse over 10 to 20 years,” Caleb Alexander, co-director of Johns Hopkins Center for Drug Safety, told CNBC’s “On The Money” in a recent interview.

“I think it’s important that we have realistic expectations about the amount of work that it will take and the amount of coordination to turn this steamship around,” Alexander added.

President Donald Trump declared the opioid epidemic a public health emergency last fall, and he announced an initiative in March to confront the national health crisis.

“No doubt there’s a lot of efforts underway at every level to address the epidemic,” Alexander explained.

“There’s a flurry of legislation right now working its way through Congress and these legislative efforts address everything from safer packaging to better use of information to try to address the diversion of prescription opioids.”

Opioids include not just prescription drugs, like OxyContin, codeine, and morphine, but also heroin and synthetic drugs like fentanyl.

But Alexander says some progress has been made in reducing the overprescribing of the prescription painkillers, “this was one of the primary drivers of the epidemic in the first place.”

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“There’s been modest declines in prescription opioid sales over the past 5 to 7 years. But we’re still way beyond the volume of opioids prescribed compared with every other country in the world. We have a long way to go before we get to the levels of opioid prescribing that we were at in the late 1990’s before this epidemic began.”

Alexander says his research is focused on identifying clinical and policy solutions to the opioid epidemic.

Beyond reducing opioid prescriptions, he sees another step as crucial in addressing the epidemic.

“We need to better identify and treat people with opioid addiction. This is a treatable condition, just like diabetes or high cholesterol and yet the vast majority of people with opioid use disorder are not enrolled and seeking care.”

Alexander added: “The statistics are stunning. More than 2.1 million Americans have an opioid use disorder or opioid addiction” and he says the country needs to “invest tens of billions or hundreds of billions of dollars” to shore up the treatment system.

He said patients should be able to access medications that “we know work to help reduce the cravings for further opioids.”

With treatment, Alexander said “they can return to normal healthy productive lives in recovery.”

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Doctors Network Develops National Guideline for Treating Opioid Addictions

A network of doctors has developed a new Canadian guideline for managing opioid use disorder, including a recommendation of which replacement medication should first be used to treat those addicted to the powerful narcotics.

The guideline, published Monday in the Canadian Medical Association Journal, was created for a wide range of health-care providers to address the urgent need for treatment of opioid use that is causing a crisis of overdoses and deaths.

In 2016, there were 2,861 opioid-related deaths in Canada. As of last June, another 1,460 deaths had been attributed to the drugs and the total number for 2017 was predicted to reach about 4,000, fueled by a combination of overprescribing by doctors and an influx of synthetic opioids, such as illicitly manufactured fentanyl and carfentanil.

“Opioid use disorder is a public health emergency nationwide and this guideline provides a blueprint for health practitioners to step up and provide evidence-based care,” said Dr. Julie Bruneau, a physician at the Universite de Montreal and lead author of the guideline.

The guideline recommends that Suboxone (buprenorphine–naloxone) be used as a first-line treatment whenever possible to reduce risk of toxicity and death.

 The drug is used as a replacement for opioids to prevent severe withdrawal symptoms, but has a much safer side-effect profile than methadone, the medication traditionally prescribed for opioid addiction.

“In British Columbia, in about one in four prescription opioid overdose deaths, methadone is actually the culprit,” said Dr. Evan Wood, director of the BC Centre on Substance Use and senior author of the guideline.

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Those prescribed methadone must visit a pharmacy daily to ingest their dose in the presence of a pharmacist and the drug’s side-effects include a sedating effect, both of which make it challenging for those trying to work or otherwise carry on with their lives, Wood said from Vancouver.

“So as a first-line medication, it doesn’t make a lot of sense.”

Suboxone is an oral medication designed for at-home use and has a minimal risk of overdose, even if taken in a large quantity at once, he said, adding that it allows those being treated to better function in life, attend a recovery program or hold down a job.

The network that developed the guideline included 43 health-care practitioners who are part of the Canadian Research Initiative in Substance Misuse (CRISM) and also involved people with opioid use disorder to consider patient preferences.

Other key recommendations:

— In people who respond poorly to buprenorphine–naloxone, consider transitioning them to methadone treatment.

— Start with methadone when buprenorphine–naloxone is not the preferred option.

— In patients who do not respond to either buprenorphine–naloxone or methadone, consider slow-release oral morphine, prescribed as daily witnessed doses.

— Avoid withdrawal management alone without transition to long-term treatment to reduce the risk of relapse and death.

Beyond recommending the use of buprenorphine–naloxone as the first-line treatment whenever possible, the guideline also identifies how certain common practices should be avoided — specifically, offering withdrawal management as an isolated strategy, which can increase overdose rates.

For those who choose to go into a detox program, in which the person reduces their reliance on opioids with the goal of abstinence, Wood said a better system needs to be developed to refer people immediately to an in-patient recovery program or intensive out-patient treatment.

“If they go into a detox program, then you want to make sure they’re linked to ongoing addiction treatment and close follow-up because the likelihood of relapse is so high,” he said.

In a related CMAJ commentary, Drs. Joseph Donroe and Jeanette Tetrault of the Yale University School of Medicine, say the expansion of access to care for opioid use disorder requires primary-care providers to take the lead, “as they do with other chronic diseases of similar complexity, such as diabetes.”

“This national guideline describing the pharmacologic management of opioid use disorder is timely and needed to address the expanding epidemic of opioid use disorder and overdose,” they write.

“Importantly, the guideline is geared toward front-line providers, who are vitally important to decrease the existing treatment gap.”

— Follow @SherylUbelacker on Twitter.

Original article here.