02-05-18 What is the latst update on treatment of opiate use disorder?

Toxicology Question of the Week

February 5, 2018

What is the latest update on treatment of opiate use disorder?

Below is a commentary by Nora Volkow MD that was recently published in the Lancet.  Dr. Volkow is Director of the National Institute on Drug Abuse at NIH.  She pioneered the use of brain imaging to investigate the effects of drugs in the human brain and has demonstrated that drug addiction is a brain disease.  She has published over 600 scientific articles and edited three books. Her commentary on the treatment of opiate addiction is insightful.  ds

www.thelancet.com Vol 391 January 27, 2018 285

For the past two decades, the USA has been in the
throes of an opioid crisis marked by a rising number of
deaths; in 2016, opioids were responsible for most of
the nation’s estimated 64 000 fatal drug overdoses.1 The
problem began with overprescribing of opioid analgesics
in the 1990s, which exposed pain patients to the risks
of addiction and produced large surpluses of pain pills
that were diverted for misuse by the larger community.
Additionally, the escalating numbers of opioidaddicted
Americans led to increased HIV and hepatitis C
transmission among people who misuse these drugs by
injecting them2 and increased numbers of infants born
dependent on opioids as a result of the mother’s opioid
use (neonatal abstinence syndrome).3
The opioid crisis has been a moving target; while it
began with the misuse of prescription opioids, this then
opened the door to an increase in heroin use.4 A decade
ago, most people who misused opioids in the USA had
initiated with prescription drugs, but now heroin is
reported as the opioid of initiation more often than the
most commonly prescribed opioids, oxycodone and
hydrocodone.5 There has also been an influx of new,
more potent synthetic opioids such as fentanyl—often
used to adulterate or replace heroin because it is cheaper
to produce and easier to import—that has increased
the danger for users and perpetuated the trend towards
increasing opioid overdose deaths.6 US Government
authorities and the medical community are addressing
the problem in a range of ways. In March, 2016, the
US Centers for Disease Control and Prevention (CDC)
revised its guidelines for opioid prescribing for chronic
non-cancer pain, recommending alternative approaches
in pain management and limitations on the dosing
and duration of opioids when they are called for.7 Law
enforcement and diplomatic efforts are being made
to stem the influx of synthetic opioids, which mostly
originate in Chinese laboratories.8 And to save the lives
of people who overdose on opioids, most US states
have taken steps to increase the availability of the opioid
antagonist naloxone to police, emergency medical
personnel, and opioid users themselves.9 This safe and
easily used medication can quickly reverse the effects of an
opioid overdose and restore breathing if it is administered
in time; and communities that have distributed naloxone
to opioid users, their families, or potential bystanders have
seen reductions in overdose deaths.9 Naloxone is now
available in an easy-to-administer nasal spray, although
multiple administrations are sometimes necessary when
overdoses involve fentanyl or other potent synthetics.
Researchers are working to develop more potent and
longer-lasting opioid antagonists to counter the fentanyl

Addiction treatment is equally important in reducing
deaths and infectious disease transmission, although
historically in the USA such treatment has been hard to
access, is not covered by most insurances, and is of variable
quality.10 Health-care reform efforts during the past
decade have begun to increase access to evidence-based
treatment for substance use disorders and to integrate
that treatment into the larger health-care system.11
Medications are the gold standard of treatment for opioid
use disorder.12 There are currently three medications
approved by the US Food and Drug Administration (FDA),
all of which target the μ-opioid receptor. Methadone and
buprenorphine have agonist effects, addressing craving
and withdrawal symptoms without producing euphoria
and are used for long-term maintenance therapy.12 By
contrast, naltrexone is an antagonist at the receptor and
prevents illicit opioids from having an effect.12
In the USA, medications are required to be given in
conjunction with some form of counselling or behavioural
therapy, called medication-assisted treatment (MAT),
but there remains a vast gap between those who
would benefit from MAT and those who receive it.13
This gap reflects both lack of treatment capacity and
an entrenched stigma against use of medications for
opioid use disorder arising from the belief that these
medications simply substitute one addiction for another.
This belief, a holdover from early models of recovery that
emphasised complete abstinence from all medications,
reflects a misunderstanding of the pharmacological and
therapeutic effects of these drugs. When an opioid user
is treated with methadone or buprenorphine, the doses
used do not produce euphoria or trigger the conditioned
responses that generate craving.12 These medications
reduce withdrawal symptoms, improve mood, and help
restore physiological balance—allowing the patient’s
brain to heal while he or she works towards recovery.12
Methadone, the first medication developed for
opioid use disorder, is less expensive than the other
Medications for opioid use disorder: bridging the gap in care.

Published Online
November 14, 2017
See Comment page 283
See Articles page 309

I am interested in any questions you would like answered in the Question of the Week.  Please email me with any suggestion at donna.seger@vanderbilt.edu

Donna Seger, MD

Medical Director

Tennessee Poison Center


Poison Help Hotline: 1-800-222-1222

The Question of the Week is available on our website: www.tnpoisoncenter.org