COMMENTARY

The Opioid Crisis: Treating the Real Cause

Tom G. Bartol, NP

Disclosures

June 19, 2017

Medical Treatment of Opioid Addiction

With Canada being the leading per capita user of prescription opioids in the world, Srivastava and colleagues[1] reviewed the literature and provided guidelines on managing opioid use disorders, particularly in the primary care setting. Specifically, they included recommendations on when methadone, rather than buprenorphine-naloxone treatments, should be used.

Evidence on three treatment methods were reviewed:

  • Abstinence-based treatment;

  • Buprenorphine-naloxone; or

  • Methadone treatment at a methadone clinic.

Overall, there is very little level I evidence (multiple large, randomized controlled trials or systematic reviews) on most of the factors investigated. The preponderance of evidence came from cohort and case-control studies (level III) and consensus (level IV).

The authors concluded that both methadone and buprenorphine-naloxone are more effective than abstinence-based treatment. Methadone treatment had higher retention rates than buprenorphine-naloxone, whereas buprenorphine-naloxone had lower risk for overdose. Methadone treatment was preferred for patients at higher risk of dropping out from treatment (eg, injection opioid users), whether they were adults, youth, or pregnant women. If buprenorphine-naloxone is used first, these patients should be quickly switched to methadone if they are experiencing symptoms of withdrawal or cravings or if they persist in opioid use.

Buprenorphine-naloxone was recommended for socially stable prescription oral opioid users, especially if their work or family commitments made it difficult for them to do daily medication pick-ups. Buprenorphine-naloxone management was also recommended for patients whose jobs require higher levels of cognitive functioning or psychomotor performance.

Viewpoint

Recently a young woman in my community was found dead; the cause was opiate overdose. She had struggled to find connection and hope in life. She wanted to feel better and had tried many things, eventually turning to recreational opiates. These drugs did not give her what she needed; but, for a while, life seemed better with than without them, and she became addicted and died. Her underlying problem that needed treatment was not opiate addiction—that was just the symptom of another problem.

In combating the opioid epidemic, the focus has been on treating those who become addicted to opioids, preventing abuse of prescription opioids, and making available treatments for opioid overdose.[2,3] The root problem of why people turn to opioids and become addicted needs more emphasis, attention, and energy. Treating the addiction is an important part of the process, but without treatment of the underlying issue, treating addiction is akin to wiping up water on the floor from a leaking roof and never repairing the roof. It is treating a symptom. At the same time, more people become addicted to drugs and other substances as they struggle with emotional problems and such conditions as posttraumatic stress disorder.

People use and abuse opioids (and alcohol and other substances) because they are seeking to feel better about something or to avoid pain. The pain is not always physical; often it is emotional pain. Opioid addiction has been found to be two to five times more frequent in people who have experienced emotional, physical, or sexual abuse in childhood.[4,5] And there are many people with life challenges, relationship problems, or low self-esteem waiting in the wings, looking for a way to feel better, who will become addicted to opioids and other substances if we simply treat addiction without addressing the root cause.

Most people who have become addicted to opioids will not enter the traditional healthcare system until they have complications from addiction. Our healthcare system is not set up to reach these people early. We need a system that doesn't wait for symptoms to develop but adapts to treat the causes of addiction.

To effectively manage the opioid epidemic, we need to change our approach to healthcare—to how we provide it and how it is reimbursed. If healthcare only takes place in a clinic or hospital, and reimbursement is only for doing procedures or treating symptoms, the epidemic will continue.

Encountering people before symptoms develop is the key. Healthcare must have more emphasis on developing connections and building relationships so that patients know and trust their healthcare providers and are willing to share their pains and challenges even in the absence of a perceived or diagnosed physical or mental health condition. This can only be achieved when clinicians have more time to spend with patients, and it also means taking healthcare beyond the clinic or the hospital.

For example, in our schools, every student would have a "check in" with the school nurse, even if the student isn't ill, as a way of making a connection to the student.[6] Healthcare could take place in the workplace, not just with blood pressure or cholesterol screening but by having providers meet with workers on a regular basis to help identify and address life challenges, stresses, and traumas.

Medication-assisted treatment is one prong of the approach needed to resolve the opioid epidemic. But more drugs will not solve the problem, even if we treat each person who becomes addicted to opioids. The enduring solution lies in addressing the underlying causes and helping people find healing and hope in a world fraught with challenges and pain.

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