The 20-year opioid overdose epidemic confronting our nation has continued unabated largely because of an uncoordinated response that has over emphasized supply-side interventions (i.e. prescriber guidelines, Prescription Drug Monitoring Programs, law enforcement) rather than dramatically increasing access to evidence-based treatment as occurred in other Western nations with great success. The White House’s Opioid Commission (chaired by Governor Chris Christie, R-NJ) in declaring a national emergency and breaking with this failed tradition offers much hope for stemming the overdose death rate.
The Opioid Commission’s interim report (released Monday July 31) emphasizes increasing access to evidence-based care for each of the 2.4 million Americans estimated to be affected with opioid use disorder. The Commission is seeking to expand access, such as through Medicaid waivers, for evidence-based treatment programs offering three Food and Drug Administration-approved, lifesaving medications to manage opioid use disorder: methadone, buprenorphine, and extended-release naltrexone monthly injections. Further, the Commission has requested that federal efforts intensify enforcement efforts targeting insurance plan violations obstructing patient access to treatment (despite mental health parity laws having been in existence for almost a decade).
Evidence-Based Treatment Needs to Be Ubiquitous
Unfortunately, evidence-based treatment has remained out of reach for the great majority of afflicted individuals; many who are lucky enough to find any treatment program receive outdated and ineffective care with brief detoxification followed by a non-medical, abstinence-only approach to recovery, an approach that may actually increase the risk of overdose. As a result, broad swaths of the population remain untreated or repeatedly relapsing to opioids, often with fatal consequences. The recent advent of fentanyl and synthetic analogs on the black market has laid waste to these vulnerable individuals much like a blazing fire burning through a dehydrated forest.
Despite human interest stories in the news, town hall hearings for increasing law enforcement, and public rallies for increasing access to naloxone (an overdose reversal agent), our national conversation has remained stubbornly unaware of the evidence base for treating people with opioid use disorder, which is the most effective strategy to prevent overdose death. Governor Christie and the Opioid Commission are now taking steps in the right direction in calling for implementing high-quality, evidence-based treatments and insisting all patients have ready access to all three medication options.
Every opioid-addicted individual should be able to walk into their local emergency room (e.g. successful pilot programs at Yale), community pharmacy (e.g. Canada’s model), police precinct (e.g. LEAD in Washington or PAARI in Massachusetts), or doctor’s office and immediately start an evidence-based medication that same day without financial or logistical barriers. Costs for medication to stabilize patients pale in comparison with those of the untreated disorder — typically estimated at over $60,000 per year per affected person.
Treatment Requires Long-Term Maintenance
Medication assisted treatment has shown to reduce mortality rates by 50 percent or more while people are retained in care. However, to be successful, medication assisted treatment requires long-term maintenance beyond initial symptom resolution, lasting years rather than months. There have never been studies demonstrating clinical benefit to premature cessation of maintenance medications. Rather, decades of evidence show the opposite: stopping medication drives relapse and death rates. As a result, the recent Surgeon General’s report on alcohol, drugs, and health directed providers to treat opioid use disorder under a chronic medical illness model, one which includes sustained health-management, post-stabilization monitoring, active linkage to recovery communities together with recovery education, medication maintenance, and early re-intervention when needed.
The most tragic stories are those of patients who did well on medication, but stopped under outdated program rules or insurance barriers and then relapsed. This would never be acceptable in any other field of medicine, but it remains a reality in the treatment of opioid use disorder. The Commission is wise to ramp up federal enforcement efforts for mental health parity.
When antiretrovirals (such as zidovudine) first hit the market in 1994 to treat HIV, AIDS mortality dropped by half within two years (see Figure 1). The success of AZT was due in part to the novelty of HIV. The virus was a new threat and the nation responded with new institutions, reformed laws and regulations, and novel payment programs for rapidly expanding access to new medications. The opioid epidemic is similarly a national tragedy and requires extraordinary measures. The Opioid Commission has finally sounded the correct alarm.
Figure 1
Author’s Note
Dr. Bisaga received honoraria, consultation fees, and travel reimbursement for training, medical editing, and market research from UN Office on Drugs and Crime, The Colombo Plan, Motive Medical Intelligence, Healthcare Research Consulting Group, Indivor for an unbranded educational activity, GLG Research Group, and Guidepoint Global, and he received medication, extended-release naltrexone, from Alkermes for NIH-funded research studies. Dr. Bisaga served as an unpaid consultant to Alkermes, Inc.
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