A new review paper by Carlos Blanco, MD, PhD, and Nora Volkow, MD, nicely summarizes current and future management of opioid use disorder (OUD)—as one would expect from two outstanding researchers. Dr. Blanco is Director of the Division of Epidemiology, Services, and Prevention Research at the National Institute on Drug Abuse (NIDA), and Dr. Volkow is the Director of NIDA.
The first sections of the article cover screening, assessment, comorbid conditions, risk factors, prevention, and patient care. Concise charts present key points on withdrawal symptoms, drug therapy, management, models of care for medications, and interventions to improve the cascade of care.
Especially valuable is the second section, Future Directions, where the authors share a wealth of suggestions for prevention and treatment, arranged by topic.
High-priority needs include evidence-based prevention of opioid use disorders in adults and older youth, and clarification of associations between risk factors. Special targets for intervention are psychiatric comorbidities and broader environmental factors, such as policies and socioeconomic conditions.
Susceptibility to OUD seems to involve multiple genes, each having a minor influence. Some genes have already been implicated. The authors recommend studies with large sample sizes to help identify the effects of single genes, and clarification of the roles of genetic and environmental factors “in increasing the risk of [OUD] within and across racial or ethnic groups.”
Because reliable genetic biomarkers for methadone treatment do not exist, the authors suggest using network approaches to identify genes that work together in raising the risk of disease, or in influencing the response to treatment. The biomarker approach seems a promising one for uncovering new targets for drug therapy.
Many factors are involved in the opioid crisis; thus medications alone will not provide a complete answer. There’s a need for current treatments to become more available, and for new medications.
A promising strategy: develop medications that:
- Are more effective
- Help provide better, longer-lasting adherence
- Improve impulse control, reduce stress reactivity, and decrease conditioning to drug cues
- Strengthen the appeal of nondrug rewards
Also suggested: repurposing existing medications, developing strategies using transcranial magnetic stimulation and transcranial direct current stimulation, and clarifying the possible therapeutic role of marijuana and its components.
Training Health Professionals
There aren’t enough adequate residency programs in addiction, and there’s a lag in treatment capacity. Because training programs might not solve the personnel shortage, perhaps trained providers who are not currently offering treatment could be persuaded to return to patient care. Helpful in accomplishing this could be “combatting stigma, enhancing institutional support, and increasing reimbursement rates.”
Little is known about OUD in older people, ethnic minorities, and adolescents, and about the possible connection between patient gender and OUD prevention or treatment outcomes. In contrast, much is known about treating pregnant women, including the beneficial effects of methadone or buprenorphine treatment during pregnancy.
The HEAL Initiative: Helping End Addiction Long-term
Congress last year allocated $500 million for the HEAL initiative—a program to improve pain management and other aspects of treatment, and to minimize reliance on opioids. Priority areas include using existing basic science data to identify new pharmacologic targets, and developing new medications, or finding new applications for those that exist.
The authors identify three major thrusts of the initiative:
- Improve medications for overdose reversal, and develop therapies for respiratory depression
- Optimize existing treatments
- Perform clinical trials to identify best practices for treating neonatal abstinence syndrome
The authors believe that the results of the HEAL initiative “should lead to important advances in the prevention and treatment of opioid use disorder.”
Blanco C, Volkow ND. Management of opioid use disorder in the USA: present status and future directions. Lancet. 2019;393(10182):1760-1772. Published online March 13, 2019. Epub 2019 Mar 14. doi: 10.1016/S0140-6736(18)33078-2.