Top U.S. health official: Opioid addiction is a chronic brain disease. Medication can help treat it.
As the U.S. continues to grapple with a deadly opioid epidemic, a top health official in the Trump administration says all options should be on the table for addiction treatment — including medication.
“It takes a culture change,” said Elinore McCance-Katz, a physician and assistant secretary of mental health and substance abuse for the U.S. Department of Health and Human Services.
The use of medication to help treat opioid addiction, though widely studied and found to be effective, does not have universal support in the recovery community. Some 12-step programs remain critical of the practice, viewing it as replacing one drug with another.
Medication-assisted treatment involves prescribing methadone, buprenorphine or naltrexone and combining it with counseling and other behavioral health therapies.
The practice is “evidence-based,” McCance-Katz said during the American Society of Addiction Medicine’s annual conference, which ended Sunday in San Diego.
“I think that people need to have the greatest number of options possible,” McCance-Katz said. “If they can find another way that helps them to get into recovery and live healthy lives, that’s really up to them.”
“But in terms of what we know and what the evidence shows us, medications to treat substance use disorders that are as severe as opioid addiction really need to be available,” she said.
Robust evidence
Chronic opioid addiction changes the brain at a fundamental level.
When people stop using opioids, they experience severe withdrawal. The prescribed medication can help a person deal with withdrawal, giving them the brain space to consider what is a healthy choice and work through counseling and other treatment.
The use of medication also has been found to lower drug-related fatalities. If someone has been abstinent for a period of time and relapses, they are more susceptible to a fatal overdose because their tolerance is low.
"The evidence here on the use of medication in a longitudinal manner to treat opioid use disorder is robust," said Kelly Clark, a physician and president of the American Society for Addiction Medicine.
"It is clear," she said.
But only a third of treatment programs offer access to medication and of those patients who would be eligible, only half receive the medication, Clark said.
The possible reasons for those statistics vary, she said.
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Some patients do not want to use medication. The cost of insurance and medication can play a role. Few doctors are trained in addiction medication.
There are also limitations of the prescription drugs.
Methadone is an opioid, making it difficult to stop using and opening it up to possible abuse. It is a controlled substance and highly regulated by the federal government.
Buprenorphine also is an opioid, but typically is less potent than methadone. Suboxone is the brand name of a commonly prescribed form of buprenorphine with naloxone, which is used to reverse an opioid overdose.
Naltrexone, commonly known by its brand name Vivitrol, helps block the effects of opioids so a person no longer feels the same high.
Many physicians have not received federal waivers to prescribe burpenohphene, and even if they have, they may be reluctant to prescribe it without counseling and other wrap-around services available.
'Hub and spoke'
One possible solution for wider access is the “hub-and-spoke” model, which has been pioneered in northeast states such as Rhode Island and Vermont and may soon come to Wisconsin.
In January, Gov. Scott Walker issued an executive order to create a commission to study the model with help from The Pew Charitable Trusts.
The hubs are facilities that specialize in stabilizing people with opioid addiction.
“What that means is we not only treat your opioid use disorder, which we do, but we also look at whether they have mental disorders, look at what their physical health problems are,” McCance-Katz said.
Once a person is stabilized, they are referred back to doctors who can prescribe medication treatment and other service providers in their communities.
If people relapse, they are referred back to the hubs to be stabilized again.
An evaluation of Vermont's hub-and-spoke program released earlier this year found a 96% drop in opioid use and 89% decrease in emergency department visits among 80 people who had been receiving treatment through the program for at least six months.
Notably, none of the study participants had overdosed in the 90 days leading up to the interview with researchers. For comparison, a quarter of them had overdosed in the 90 days before entering treatment.
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Experts say the hub-and-spoke concept could face challenges in Wisconsin: It’s a much larger state with many different insurers, and although Wisconsin partially expanded its Medicaid health program known as BadgerCare Plus, it didn't do so fully.
But it's clear the need is urgent.
In Wisconsin, emergency room visits for opioid overdoses have soared, jumping 109% from July 2016 through September 2017, according to data released last month from the Centers for Disease Control and Prevention.
The state recorded 827 opioid overdose deaths in 2016, the most recent year statewide data is available. In 2017, Milwaukee County alone recorded 337 opioid-related deaths.
A 2016 study in Wisconsin found only 23% of patients with a substance use disorder received treatment, said Alexandra Duncan, a senior officer with The Pew Charitable Trusts’ substance abuse prevention and treatment initiative.
“Any comprehensive system to address opiate use disorder must rely heavily on community-based providers,” she said.
Editor's note: This article was reported with the support of the National Press Foundation, which awarded fellowships to 15 journalists to attend the American Society of Addiction Medicine's annual conference.