Treatment of Opioid Dependence: A Call for an Evidence-Based Approach

evidenceDespite decades of accumulated data on the effectiveness of medication-assisted treatment (MAT), gaps remain between evidence-based standards and current practices. The authors of a recent study attribute these gaps largely to “regulatory constraints and pervasive suboptimal clinical practices.” The study appeared in August in Health Affairs; the authors are affiliated with U.S. or Canadian medical institutions. This article focuses on the findings and recommendations pertaining to the U.S.

Based on evidence from many randomized trials, large-scale longitudinal studies, and meta-analyses that show the effectiveness of MAT, the authors recommend four policy changes:

  • Eliminate restrictions on office-based methadone prescribing, and adopt the direct administration and dispensing of methadone in pharmacies. This will require changes in federal and, in some cases, state law.
  • Reduce financial barriers to treatment, such as copayment variations. Provide universal coverage for MAT via public and private insurers.
  • Reduce reliance on opioid detoxification; strong scientific evidence shows that some types are ineffective and possibly harmful.
  • Create and evaluate mechanisms to integrate emerging treatments, such as slow-release buprenorphine implants.

These steps, the authors believe, “can greatly reduce the harms of opioid dependence by maximizing the individual and public health benefits of treatment.”

Following is a discussion of the authors’ specific concerns and recommendations.

Office-based methadone prescribing. The authors note that access to methadone in the U.S. is heavily regulated and “more restricted in the United States than elsewhere in the developed world.” Fewer than 10 percent of all opioid-dependent people in the U.S. currently receive treatment—yet the number of methadone-prescribing facilities has changed little since 2002. Currently only about 8 percent of all substance abuse treatment facilities offer methadone maintenance treatment (MMT).

Treatment in doctors’ offices would offer a less-stigmatizing environment, and would facilitate care of co-occurring conditions, such as HIV and hepatitis C. Moreover, providing methadone under direct observation would virtually eliminate any risk of methadone abuse or diversion.

Experience in Canada shows that office-based MMT could greatly increase patients’ access to treatment. Canada implemented office-based MMT in 1996. In 2012, the number of patients receiving methadone treatment in British Columbia increased from 2,800 to 13,000, and in Ontario it rose from 700 to almost 30,000. These figures suggest that office-based MMT in the U.S. could help meet the increased demand that health reform is expected to produce.

Expanded access would require greater participation by physicians. The authors suggest mandating addiction education in medical schools and increasing the financial incentives for providing treatment, including specifying physician billing codes.

Financial barriers. Evidence clearly shows the economic value of treating drug dependence, yet public and private insurers do not provide widespread coverage of opioid misuse disorders. Moreover, privatization of methadone clinics is increasing, leaving few options for patients who lack insurance and are unable to pay.

Detoxification. The authors come down hard on detoxification leading to planned abstinence, calling it “the most damaging aspect of current treatment of opioid dependence.” They refer specifically to two regimens: detoxification after maintenance treatment, and detoxification (typically 12 weeks) designed to taper the methadone dose to zero. They cite evidence revealing a high risk of relapse into illicit opioid use, and an increased risk of mortality within the month after relapse. 

Potentially useful, however, is detoxification lasting up to one week, designed to treat patients who have overdosed or have severe withdrawal symptoms. Sustained abstinence is not a goal, but subsequent long-term MAT is an option patients have.

Emerging treatments. The past decade has seen several new or potential treatments for opioid dependence. They include slow-release buprenorphine implants, injectable naltrexone, and agents that bind to and activate opioid receptors (eg., injectable diacetylmorphine or heroin maintenance as a second-line treatment for heroin dependence). Although the future status of these emerging treatments is uncertain, the authors stress the benefits of having options available.

The authors note that the Affordable Care Act has the potential to eliminate gaps in treatment coverage, and it “mandates the inclusion of substance abuse and mental health services in the essential benefits that the new state insurance exchanges must offer.”

The authors also emphasize that their recommendations are initial steps, and their list is not exhaustive. “The social and structural reasons behind the low rates of access to this treatment—including stigma and discrimination perpetuated by contradictory social policies that simultaneously treat addiction as a health problem and a crime—must also be addressed.”

Reference

Nosyk B, Anglin MD, Brissette S, Kerr T, et al. A call for evidence-based medical treatment of opioid dependence in the United States and Canada. Health Aff (Millwood). 2013; Aug;32(8):1462-1469. doi: 10.1377/hlthaff.2012.0864.

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