More than 2 million Americans are estimated to have opioid use disorder (OUD), placing them at a 20-times greater risk of early death due to overdose, infectious diseases, trauma, and suicide when compared with the general population. Efforts to stem this growing crisis have mostly been unsuccessful, due in large part to already-existing tools—especially the FDA-approved medications methadone, buprenorphine, and extended-release naltrexone—not being maximally deployed, explains Alan I. Leshner, PhD. In 2017, less than 35% of those who required such treatment for OUD actually received it. The situation is worse in the prison system, where only one in 20 OUD patients receive treatment and where some sites ban these medications. “Banning OUD medications does not make scientific sense,” says Dr. Leshner. “Withdrawing treatment only has negative outcomes. This isn’t done with other medications, such as those for blood pressure or diabetes.”
Studying the Evidence
To support the dissemination of accurate patient-focused information about treatments for addiction, and to help provide scientific solutions to the current opioid crisis, Dr. Leshner and a committee commissioned by the National Academies of Sciences, Engineering, and Medicine developed a consensus study report to examine the evidence base on medication-assisted treatment (MAT) for OUD, resulting in seven main conclusions (Table). To that end, the committee argues for the replacement of the term “medication-assisted treatment” with “medication-based treatment,” to emphasize the more central role for OUD medications. “Conceptually, treatment for OUD can be solely medication-based as opposed to thinking of treatment as being behavioral therapy-based with medication only assisting,” Dr. Leshner explains. “Studies show that patients who receive longer-term treatment with medication for OUD have the best outcomes.”
The effectiveness of these medications and why they are not more widely used are the focus of the report, with the writing committee stressing that most of the factors impeding their full use can and must be dealt with to achieve substantial progress in curing the opioid epidemic. Misunderstandings and stigma surrounding OUD, as well as the medications used to treat it, are key factors, along with “counterproductive ideologies that consider addiction simply a failure of will or a moral weakness, as opposed to understanding opioid use disorder as a chronic disease of the brain that requires medical treatment,” write Dr. Leshner and colleagues. “This misunderstanding and stigma must be addressed; they have resulted in hundreds of thousands of patients being denied access to life-saving medications on non-medical, non-scientific grounds, which our committee considers to be unethical.”
The report notes that while excess regulations prevent many patients from obtaining methadone and buprenorphine, in part because of risk of diversion, extended-release naltrexone can be prescribed by any licensed healthcare professional as it is not considered likely to be abused or sold. Methadone can only be dispensed by Substance Abuse and Mental Health Services Administration-certified, Drug Enforcement Administration (DEA)-registered programs, with many patients who receive the medication required to visit treatment programs daily. Also, only 2% to 3% of physicians in the US have undergone additional training and obtained a waiver from the DEA to prescribe buprenorphine. These regulations are supported by little or no evidence, vary by state, often restrict take-home medication privileges, require supervised medication consumption, and mandate the frequency of urine testing and counseling, explains Dr. Leshner.
Meanwhile, countries like England, Canada, and Australia allow methadone to be prescribed in primary care clinics, and prescriptions to be filled at community pharmacies. With pilot studies suggesting that allowing for both could improve access in the US, support for allowing methadone to be prescribed for OUD in a range of clinical settings is increasing, according to the report.
Patients with OUD, as well as the medications used to treat OUD, face high levels of stigma from both the general public and professionals in healthcare, law enforcement, and corrections, posing significant barriers to medication-based treatment. In fact, a large study of primary care physicians found their rates of stigma toward individuals with prescriptions for OUD were as high as or higher than those among the general public. “Stigma toward the opioid agonists appears to be grounded in the misperception that these medications are simply substituting one drug for another; we don’t think that way about insulin, for example,” says Dr. Leshner. However, evidence is emerging that clinicians develop more positive perceptions about the role of medications in effective OUD treatment as they gain experience in treating this patient population with buprenorphine. Other studies are identifying and testing the effectiveness of communications strategies targeting the general public and the aforementioned professionals to help reduce stigma and encourage entry into medication-based treatment.
“It is very important that clinicians who support and understand the benefits of medication-based OUD treatment share their knowledge with their colleagues across any specialty that may treat this patient population,” Dr. Leshner says.
National Academies of Sciences, Engineering, and Medicine. 2019. Medications for Opioid Use Disorder Save Lives. Washington, DC: The National Academies Press. https://doi.org/10.17226/25310.