Prescription drugs are effective treatments for opioid addiction. Expanding access won’t be easy.
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There was a record number of drug overdose deaths in the U.S. last year — more than 107,000. And most of them were the result of heroin, fentanyl and other opioids.
The cost of the opioid epidemic — in lives and in the suffering of those with addiction, their family and friends — is incalculable.
But we can put a number on the economic cost of the epidemic: $1.5 trillion in added healthcare spending and lost productivity in 2020, according to a report by the Congressional Joint Economic Committee.
The Biden Administration recently announced $1.5 billion in annual grants to states and tribes for opioid treatment programs (OTPs) and other services to take on the epidemic. One goal of that spending is to increase the use of medication to treat opioid use disorder.
But it’s an uphill battle.
Game-changing benefits, limited access
Two years ago, Courdray Rose was struggling with addiction. “I was on the streets of Portland, homeless and using various opiates, and also methamphetamines,” said Rose. “And eventually, opiates took over my life.”
The 28-year-old recently attended an annual celebration and fundraising event for Oregon Recovers. Rose works for a peer-support group, 4D Recovery, helping other young people trying to recover from substance use disorder.
“I think one of the things that helped me the most in my recovery was medically-assisted treatment (MAT),” he said. That’s using prescription drugs — some of them derived from opiates — to help people experiencing opioid use disorder (OUD) deal with their cravings and withdrawal symptoms, stop using illegal and dangerous opioids, and live normal lives.
“It just completely changed the game for me,” Rose said. “It’s made it to where I can hold down my job. I’ve worked at my job over two years now, longest I’ve ever kept a job. I’ve been sober the longest I’ve ever been sober.”
Medications that work
The FDA has approved three medications for treating opioid addiction: methadone, buprenorphine and naltrexone.
In an interview that accompanies a recently published policy paper, Dr. Rahul Gupta, who serves as director of the White House Office of National Drug Control Policy, told the New England Journal of Medicine that MAT works.
“When we use these medications, we have people much less likely — in fact, 82% less likely — to die from an overdose,” said Gupta. “There’s tremendous amounts of benefit — including cost to the healthcare system and utilization, as well as to the justice system — of using medications.”
That’s great for the nearly 8 million Americans Gupta said are currently experiencing opioid use disorder. But, he said, “only less than 5% of those individuals are able to get treatment today as it stands.”
The Biden Administration wants to achieve universal access in three years by reducing federal, state and local barriers to prescribing and dispensing these medications. And there are plenty of barriers.
When recovery comes with restrictions
The Drug Enforcement Administration, Substance Abuse and Mental Health Services Administration and other federal agencies keep tight control of opioid treatment programs that dispense the oldest and most-used addiction medication: methadone.
Doctors and clinics can prescribe the newer addiction medication buprenorphine, but they need a special federal waiver, called an x-waiver, to do so.
Many states and localities also restrict where treatment can be delivered and how it can be funded.
In West Virginia, for example — with the highest overdose death rate in the country — there’s a moratorium on opening any new opioid treatment programs.
“It does sometimes feel like we’re banging our head against the wall,” said Lee Storrow, director of Regional and National Policy at the West Virginia- and Washington, D.C.-based Community Education Group. He’s been lobbying the West Virginia legislature to lift the moratorium, which came close to happening in early 2022.
“It is no secret that the opioid epidemic has hit West Virginia really hard,” Storrow said. “Overdose death rates have doubled over the last 15 years. And the tool that we know — decades of research have shown methadone to be safe and effective in reducing drug use — we cannot have a new provider open.”
Hopes for expanding care
Currently, Storrow said there are nine opioid treatment programs that can dispense methadone in the state. “West Virginia is a very rural state, and the road infrastructure — the tool is not possible to do daily dosing if you are living more than an hour away from the closest methadone clinic.”
Storrow believes that making more non-methadone-based medication treatment available via university medical centers would help, even with the moratorium still in place. “That would allow our leading experts at West Virginia University and Marshall University in medication-assisted treatment to operate and open new clinics, to do that kind of innovation.”
Dr. Jeanmarie Perrone, professor of emergency medicine and director at the Penn Medicine Center for Addiction Medicine and Policy, argues that prescribing MATs should be possible for more doctors, hospitals and medical clinics. Expanding telehealth, including extending temporary rules instituted during the pandemic, would allow MAT to reach more people in rural areas with limited access to treatment and healthcare services, she said.
It should also be easier for patients to stay in treatment, even if they don’t pass drug tests or attend counseling sessions, Perrone added.
“Counseling can be a big burden,” she said. “A lot of opioid treatment programs require patients to come in three days a week for group. And on top of coming in every day to get your methadone, that’s not conducive to working and having a family.”
More than medication is needed
But expanding access to medication without other mental health supports isn’t likely to work for most patients, said Dr. Nasser Khan at Acadia Healthcare, who oversees a chain of opioid treatment centers and other facilities around the country.
Khan agrees that getting more people on medication is crucial: “The tip of the spear is to prevent overdose. And medication, by reducing those cravings, is critical to preventing patients from using again and relapsing and potentially overdosing.”
But, he added, “I would argue that that’s insufficient. Medication alone doesn’t teach patients new strategies, it doesn’t help them build new peer groups, it doesn’t help them critically examine their behavioral patterns.”
Recovery on the road
One measure to expand care is getting traction nationwide: taking opioid treatment on the road.
“It’s unacceptable that people that are trying to turn around their lives are forced to commute upwards of an hour to get a life-sustaining treatment,” Khan said. “By putting a mobile van in the community, now I’m able to treat people.”
It’s a good start, he said. But there’s more demand outside urban Portland than the treatment van can service at this point.
All over the country, there’s a desperate need for more brick-and-mortar clinics—from big cities to small towns. Local regulations, fear of the opioid epidemic and lack of funding don’t make ramping up to meet that demand easy, Khan added.
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