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A complex response to an epidemic

December 11, 2013
by Marvin D. Seppala, MD
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Marvin D. Seppala, MD

The United States is in the midst of an opioid epidemic. Deaths from drug overdose, driven by the increase in prescription opioid abuse, now outnumber those caused by car accidents. Systematic changes in the approach to pain management, both in physician practice and patient expectation, have resulted in dramatically increased prescription of opioids to treat pain. Today, Americans make up 4.6% of the world’s population but consume 80% of the global opioid supply, including 99% of hydrocodone.1,2,3

These rampant, ongoing prescribing practices have corresponded with increased abuse and dependence, a huge jump in emergency-room visits and addiction treatment center admissions, and a frightening increase in overdose deaths. The Centers for Disease Control and Prevention (CDC) noted a 300% increase over 11 years in prescription painkillers sold. More than 125,000 opioid overdose deaths have occurred in the U.S. over the past 10 years,4 and we’ve recently learned that the death toll increased fivefold between 1999 and 2010 for women, while increasing 3.6 times for men.5


The peril of inadequate training

We in the addiction treatment field know that treatment does not occur in a bubble. We’d like to believe that addicts who seek help find it—compassionate, trained, qualified help. Unfortunately, many patients are tapping into inadequate treatment—and in the case of opioid addiction this results in a particularly dangerous situation.

Individuals addicted to opioids are extremely vulnerable. They are hypersensitive to physical and psychic pain, putting them at greater risk of relapse; they are more likely than other patients to leave treatment before completing it; and they are at higher risk of death from accidental overdose during relapse because of their reduced tolerance levels.

As a result, the opioid epidemic—and the opioid addict—demands a unique, specific, evidence-based solution, one that gives the individual the best chance at long-term recovery.

Hazelden, a world leader in addiction treatment since 1949, recently added new treatment protocols specifically for those with opioid dependence. The new programming includes changes to traditional group therapy and lectures and involves extended, adjunctive medication-assisted treatment (MAT).

Herein lies the distinction: Medications alone are not adequate for treating the complex condition of opioid addiction. In physicians’ offices across the country, primary care doctors who have undergone the Drug Enforcement Administration’s (DEA’s) mandatory eight hours of training to prescribe buprenorphine—and then do not follow up with any other treatment—are doing a tremendous disservice to their patients. They serve as a buprenorphine clinic: highly profitable and dangerously misleading.

At the other end of the spectrum, abstinence-based 12-Step treatment programs refuse to consider MAT. This is an equivalent disservice, as these programs lose a tremendous opportunity to engage more patients in recovery and save lives. The treatment field is arguing over treatment philosophy in the midst of a crisis.

A 2011 study found no difference in the basic use of buprenorphine with medical intervention versus counseling and medical intervention.6 While some interpret this finding to mean that counseling and other recovery management activities are unnecessary, the study authors suggested that more intensive, longer-term counseling could have a significant impact on effectiveness, and they are studying this now.6

For some people, medication is enough. For others, a 12-Step program is enough. The current science does not help us to identify which treatment works for what person. But in the review of the overall population of people with opioid dependence, a single treatment is not enough—addiction is a complex brain disease that alters reward, motivation, memory and related circuitry. These alterations manifest in biological, psychological, social and spiritual dysfunction.7 Medication only treats the biological aspects of this illness, and patients will not achieve the full gains of broad treatment using all the methods that we consider necessary for people entering recovery.

There is a fundamental gap between short-term detoxification and long-term recovery that is missed when patients are handed medication and waved out the door, or when they are just told to go to meetings.

These methods need to be reconsidered. Over the short run when people use buprenorphine, they quit using heroin and prescription opioids and they feel better. But in the long run, the majority of these patients stop taking buprenorphine, use other substances, and without any other tools or form of treatment they are likely to relapse.8,9,10,11,12 MAT should be used to engage patients long enough for them to complete psychosocial treatments, acquire new information, establish new relationships and become solidly involved in recovery—not as the be-all, end-all answer to opioid addiction.

For primary care physicians, it would be ideal to partner with an outpatient addiction treatment provider and to require patients on MAT to attend treatment programming that considers the psychological, social and spiritual aspects of recovery. Additionally, Hazelden offers an excellent educational opportunity in its Professionals in Residence (PIR) program, which allows physicians who haven’t had an addiction fellowship to learn about the robust nature of psychosocial therapies and 12-Step programming that could improve their practice and use of these medications as well as enhance their patients’ outcomes.