THE TREATMENT OF OPIOID
ADDICTION
Mark Jorrisch, MD
T
he United States is in the grips of one
of the worst epidemics of heroin and
other opioids in its history. Government
studies estimate the number of heroin users
to be about 330,000 and growing, up about
75 percent from five years ago and up almost
three times compared with the decade low of
119,000 in 2003. All told, heroin and related
prescription opioids have killed more than
125,000 in the U.S. in the past 10 years. What
treatment options are available and which work best?
ABSTINENCE-BASED VS. OPIATE
AGONIST TREATMENT
With the current regional and national opioid addiction epidemic
there has been a strong movement by specialty societies to re-frame
treatment and measures of success. Success need not be based solely
on the person becoming totally medication free (consider most
other medical disorders such as diabetes, hypercholesterolemia, or
hypertension) but on other measures. Measures of success should
include cessation of illicit drug use, retention in treatment, end of
criminal involvements and gainful employment.
Abstinence-based programs usually rely on an initial
detoxification, often while hospitalized, followed by counseling
and other psychological support. Long-term residential programs
are often not readily available mainly because of expense. Outpatient
programs of varied length utilize such techniques as cognitive
behavioral therapy, motivational enhancement therapy, contingency
management and twelve step facilitation, all of which have a good
evidence base for success. A significant downside of the abstinence
based approach, however, is the limited retention in treatment
during the early course as patients struggle with unmanageable
and prolonged withdrawal symptoms.
STANDARDS OF PRACTICE
Treatment options for opiate addiction fall into two general categories:
abstinence-based treatment and Opiate Agonist Treatment (OAT).
The alternative approach is Opiate Agonist Treatment (OAT),
specifically agonist treatment with methadone (full agonist) or
buprenorphine (partial agonist available in various formulations
including generic tablets and branded Suboxone, Zubsolv, and
Bunavail). Naltrexone (antagonist) will not be further discussed
in this article.
Opioid agonists are well established as treatment both for
withdrawal and maintenance but are only available from licensed
facilities. The success of this approach is well-established and dates
back to the days of the Lexington Narcotic Farm, established in 1935,
and to the Dole and Nyswander studies that established methadone
as a viable treatment for narcotic addiction as far back as 1964.
Unfortunately, there have been controversy and stigma attached
to both medications as a result of misuse, mismanagement, and
poor practice. Being viewed as a ‘drug’ rather than as a ‘medication’
interferes with the availability and widespread use of methadone
and buprenorphine as a treatment for opioid addiction.
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opiate use disorders, alcohol use disorders, and tobacco use disorder
now play prominent roles in treatment. This is likely the future
of addiction medicine as well as other brain diseases. This better
understanding of the pathology of addiction will likely lead to new
and innovative approaches for treatment.
Using opioid agonists early in treatment both for acute and postacute withdrawal leads to improved retention in treatment. Cost
savings to the community for addiction treatment in general saves
$4 in health care costs and $7 in law enforcement costs for every
dollar spent (ONDCP Fact Sheet). Methadone is the standard, and
buprenorphine has shown equal efficacy in maintenance treatment.
Some studies do show improved retention in treatment with
methadone. Comparison studies with abstinence-based p