Read the full article here.
As the opioids overdoses deaths soar and the supply of fentanyl grows, we see a flood of articles promoting harm reduction and removing the restrictions of methadone and buprenorphine, two medications claimed to reduce mortality by 50%.
The broad elements of harm reduction is increase access to syringes and the widespread distribution of the opioid reversal medication naloxone. Saving lives is and should have the highest priority. The Federal Government recently started publishing statistics on opioid reversals and the most recent figures show 180,000 overdose reversals in a 12-month period. It is hoped many of the patients revived by naloxone will seek treatment, but there is no way of knowing how many will.
Methadone and buprenorphine are considered the standard of care and there is widespread belief that increasing access to these two medications will make a significant difference in reducing overdose deaths. The restrictions placed on these two drugs are viewed as a major barrier and to accessing these two life-saving medications. Brian Mann does not write about the historical reasons for the restrictions on these two medications. Methadone and buprenorphine are opioids with a high potential for abuse, misuse, diversion, and fatal overdoses particularly with methadone. There is no doubt methadone has worked because of the restrictions. Administration of methadone in clinic setting causes a lot of inconvenience but saves lives. It makes sense to relax some of the restriction, but nobody has a good solution. Allowing any physician to prescribe methadone for the treatment of opioid addiction is going to be problematic. It will turn into a street drug, leading to a steep increase in overdoses deaths. We have a precedence for this when methadone was promoted as a low-cost opioid to treat chronic pain. The AATOD (The American Association for the Treatment of Opioid Dependance) is cognizant of this potential problem and is opposed to methadone being prescribed by any licensed physician and any retail pharmacy filling the prescriptions. There is also the risk of methadone pill mills.
There are other practical problems in prescribing methadone. Community pharmacies may be reluctant to stock the medication because methadone still carries stigma. Others may question the doses prescribed. Unlike buprenorphine, the effective doses of methadone vary considerably. What if the daily prescribed dose of methadone was 120 mg. Will the pharmacy be comfortable dispensing a 30-days’ supply? Patients on methadone may feel uncomfortable or stigmatized to go a community pharmacy to have the prescription filled.
A big unknown is how many physicians will be willing to prescribe methadone for the treatment of opioid use disorder? Less than 5% of US physicians have obtained the DEA waiver to prescribe buprenorphine. It is likely that even fewer will be interested in prescribing methadone.
Right or wrong, prescribing an opioid carries a level of stigma, especially after the disaster of prescribing opioids to treat ‘chronic’ pain. What assurance do we have that a similar problem will not arise with the treatment of patients with ‘OUD’. What objective tests can doctors employ to diagnose and confirm OUD. How often will patients have to be tested for illegal opioids and what happens if they test positive. One of the big frustrations for physicians is patients losing their meds. How will physicians deal with this problem.
If we are serious about addressing the opioid epidemic, bold measures will have to be taken. OUD is a complex psychosocial problem which cannot be treated with a monthly prescription of a substitute opioid. Most of the patients have a plethora of other issues ranging from legal to psychiatric symptom. The Federal Government should increase funding for specialized clinics that offer comprehensive services under one roof. There must be an acknowledgement that the opioid epidemic cannot be ended by just one class of treatment – opioid substitution. We are told OUD is akin to other chronic disorders like diabetes and hypertension. We treat these disorder with many medications in different classes. Not one of the medications for the treatment of diabetes or hypertension is addictive, abusable or has street value. We are in urgent needs of newer class of medications that are non-abusable and have no street value.
There is much we can learn from a different class of medication deployed extensively and is saving lives. Naloxone belongs to a very different class of opioids. Naloxone is highly effective, incredibly safe and has no street value. We have a medication in the same class that is for all purpose ignored and vilified. Naltrexone was developed as a non-addicting medication to prevent relapses in patients detoxed from opioids. Its potential application is greater in the present situation when we have not found a way curb the supply of drugs like fentanyl coming into the country. It is astonishing that highly regarded investigative reporters and writers have not investigated why this medication is not utilized. There are virtually no articles on the limitation of opioid substitution in fighting the opioid epidemic.
I am not surprised that Brian Mann missed the mark in the piece on NPR.