Opioid Crisis in America: Experts Call for Action

Alicia Ault

April 07, 2017

Addiction experts, including the head of the National Institute on Drug Abuse (NIDA), are lobbying for greater support for addiction treatment, particularly medication-assisted treatment (MAT), to address America's opioid addiction crisis.

At a special press briefing on Capitol Hill organized by the American Psychiatric Association (APA) and the American Society for Addiction Medicine (ASAM) that featured NIDA director Nora Volkow, MD, leading psychiatrists and other experts noted that in addition to a lack of education and training, stigma still prevents many clinicians from helping those with opioid dependence and other substance use disorders.

"We happen to be very lucky that we have medications that work to treat opioid use disorder," said Dr Volkow. The drugs — methadone, naltrexone, and buprenorphine ― "prevent overdoses, they prevent relapse. But they are not being implemented," in part because of stigma, she said.

"We're treating [addiction] as if it were a voluntary behavior," said Dr Volkow, who added that infrastructure remains inadequate to treat the vast numbers of those in the United States who have opioid use disorder.

"There are plenty of people out there who would like to have medications to treat opioid dependence but just don't have access," Kyle Kampman, MD, one of the speakers, who is professor of psychiatry at the Perelman School of Medicine, University of Pennsylvania, in Philadelphia, told Medscape Medical News.

The Substance Abuse and Mental Health Services Administration (SAMHSA) recently reported that in the past year, more than 10,000 physicians have become certified to provide in-office buprenorphine treatment. Slightly more than 3000 have become certified to provide MAT for an upper limit of 275 patients. A total of 37,647 clinicians have certification to offer MAT to 30 patients or more, according to SAMHSA.

Unacceptable Care

Dr Volkow believes the medical establishment has been too complacent.

"One of the main factors contributing to this epidemic is the healthcare system doesn't think this is an issue for them," Dr Volkow told Medscape Medical News.

She said that too often, she hears of individuals with opioid use disorder who are discharged from an emergency department without care or follow-up instructions and who overdose soon after. "That is improper medical care, and it is unacceptable," she said.

Insurers' reluctance to cover MAT for opioid use disorder presents another obstacle, as does the perception in many recovery programs that drug therapy amounts to simply swapping one addiction for another, said speakers at the briefing.

Ginny Atwood Lovitt, whose brother Christopher died of a heroin overdose, said that while on maintenance therapy, he was told by peers in a support group that he was not truly clean.

His community told him he was "taking the easy way out and cheating," said Lovitt, executive director and cofounder of the Chris Atwood Foundation, a nonprofit organization devoted to increasing access to naloxone. Atwood said that her brother felt shamed, went off his maintenance therapy, and ended up overdosing soon after.

"There's a lot of tradition in the treatment of addiction that gets accepted as standard, whereas the evidence-based treatments need to fight for their place at the table," said Dr Kampman.

Some of the traditional 12-step programs "are more open to medication-assisted treatment," but it is still not widely accepted, he added.

Relapse Prevention

At the briefing, Dr Kampman described the pros and cons of the three medications that have received approval from the US Food and Drug Administration for the treatment of substance use disorder and opioid use disorder. It is not clear which is best for opioid dependence, because they have not been tested head-to-head, he said.

"The medications I've talked about today do not cure anything," said Dr Kampman. "At best, they help prevent relapse. They are the glue that helps our patients stay in treatment," he said.

Treatment programs need to place more emphasis on evidence-based treatments such as MAT, said Dr Kampman. Dr Volkow agreed, adding that she would like to see more quality control over the programs, as well as utilization of a continuity-of-care model.

Such a model would include screening for substance use disorders, determining how many of those who screen positive return for treatment, how many receive treatment, and an assessment of outcomes, she said.

She also said more training in diagnosing and treating substance abuse is needed, starting in medical school. Dr Volkow said she is working with the APA to expand addiction training among psychiatrists, who often are the first to see a patient at risk, owing to the fact that such patients have preexisting mental health problems.

These clinicians are on the front lines, and yet education in substance use disorders "is neglected in many of these specialty training programs in psychiatry," said Dr Volkow.

Although many clinicians may be reluctant to work with those with opioid use disorder, Dr Kampman said it is rewarding. "I can help them. We have medicine that works, we have counseling techniques that work – people get better."

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