Opioid Treatment Hampered by Beliefs Not Grounded in Science

Posted on: December 17, 2018 Topics: addiction, addiction treatment, evidence-based medicine, opioids

Close up overhead view of full prescription bottles on stainless steel backgroundA breadth of academic research demonstrates that there are three medications that successfully treat opioid use disorder (OUD): methadone, buprenorphine, and naltrexone. However, patients face unnecessary barriers to evidence-based treatment from government regulations and providers’ own beliefs that are not grounded in science, writes Richard Saitz, professor and chair of community health sciences, in an Annals of Internal Medicine editorial.

“Patients should be given every option in their treatment for opioid use disorder and work with their clinicians to determine the best treatment plan for them,” says Saitz, who co-authored the editorial with Josh Barocas, an infectious disease physician at BMC and assistant professor of medicine at the School of Medicine.

Providers should evaluate treatment for OUD like any other chronic illness, the authors write, which means assessing the efficacy, cost, and risks and benefits analysis when determining treatment plans with their patients.

Unlike many chronic conditions, two of the three medications for OUD are limited by regulations. Methadone is only available in federally certified treatment programs and buprenorphine can only be prescribed by physicians, physician assistants and nurse practitioners who have completed training and have been waivered by the Drug Enforcement Administration. Most physicians do not have this waiver, and many who do are not prescribing buprenorphine at all.

Both methadone and buprenorphine are opioid agonists that reduce cravings for illicit substances like heroin. Despite much evidence to the contrary, some critics have called use of these medications “substituting one drug for another.”

The third medication used to treat OUD, naltrexone, is not subject to such regulations and is favored among some institutions because it is not an opioid. However, the medication is an opioid antagonist, preventing opiate effects in the brain, and requires opioid-free detoxification for approximately one week, which can be difficult for some patients with OUD. The authors cite research that shows treatment with naltrexone is more expensive than buprenorphine, and that there are safety concerns with increased overdose risk if a relapse occurs.

“If clinicians and programs are limiting treatment to only offer naltrexone because of their beliefs or institutional beliefs, they are providing inferior care,” Saitz says.

“With the growing number of individuals with opioid use disorder, we cannot allow beliefs about medications to blur the evidence showing methadone and buprenorphine to be safe and effective treatment,” Barocas says.

Stemming the rising number of overdose deaths is a key public health priority across the country, the authors write. To do so, they recommend removing bias and unnecessary regulation from decisions about treatment.

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