In Fighting An Opioid Epidemic, Medication-Assisted Treatment Is Effective But Underused
2016; Project HOPE; Volume: 35; Issue: 6 Linguagem: Inglês
10.1377/hlthaff.2016.0504
ISSN2694-233X
Autores Tópico(s)Pain Management and Opioid Use
ResumoReport From The Field Health AffairsVol. 35, No. 6: Behavioral Health In Fighting An Opioid Epidemic, Medication-Assisted Treatment Is Effective But UnderusedChristine Vestal Affiliations Christine Vestal ( [email protected] ) is staff writer at Stateline, in Washington, D.C. PUBLISHED:June 2016Free Accesshttps://doi.org/10.1377/hlthaff.2016.0504AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSAddictionPharmaceuticalsDrug useAccess to careHIV/AIDSNursesPhysiciansPrescription drugsPatient careSubstance use disorderColleen LaBelle first heard about buprenorphine when she was treating AIDS patients at Boston Medical Center. It was early 2002, and the hospital’s chief of internal medicine had asked her to go to Washington, D.C., with him to be trained on administering the soon-to-be approved opioid addiction medicine.At the training sessions, four physicians who had been conducting trials of the addiction medication before it was approved by the Food and Drug Administration spent the day reporting what LaBelle considered miraculous results.“I walked away from there completely inspired that here was something we could offer people struggling with injection drug use,” said LaBelle, a registered nurse.Like many medical professionals who learn about the potentially life-saving addiction medication for the first time, LaBelle was wowed. As soon as buprenorphine was approved in late 2002, she and two physicians at Boston Medical Center began to treat AIDS patients who were struggling with heroin addiction.“People started feeling normal within a few days,” she said.When they saw how well the drug worked for their existing patients, LaBelle and the doctors quickly developed a team approach for efficiently initiating drug users on the new medication and keeping them in treatment for as long as possible. They opened their doors for larger-scale buprenorphine treatment in 2003 and almost instantly had a waiting list of more than 300 people. Beyond their existing AIDS patients and usual group of low-income patients from nearby neighborhoods, LaBelle said they got calls from doctors, lawyers, and other high-level professionals who had done their homework on the new drug and knew this was one of only a few places in the country where they could get it. Within a few years, the AIDS epidemic had given way to a more pervasive health emergency. By 2009, heroin and opioid painkillers such as OxyContin, Percocet, and Vicodin were killing more people than motor vehicle accidents, according to the Centers for Disease Control and Prevention (CDC). 1 And the deaths were not limited to inner cities and high-risk demographic groups. The opioid epidemic was affecting people from all walks of life and all ages, in cities, suburbs, and small rural towns. In 2014, the number of drug overdose deaths topped 47,000, about 60 percent due to opioid painkillers and heroin. 2 According to the CDC’s National Center for Health Statistics, during 1999–2014 more than 165,000 people died in the United States from overdoses related to prescription opioids, and 56,000 died from heroin overdoses. 3 The most recent CDC data indicate that the rise in opioid overdose deaths has not yet peaked. The number of deaths grew more than 14 percent in 2014—the highest one-year increase yet. 2 With greater availability of illicitly produced fentanyl, a pain drug that is 100 times stronger than morphine, CDC officials fear the data for 2015 will show an even steeper increase in deaths. Effective, But UnderusedBuprenorphine is a synthetic opioid known as a partial agonist that blocks drug cravings and eliminates physical withdrawal symptoms without producing a high, unless used incorrectly. Sold most often as Suboxone, it includes another drug called naloxone, which blocks the euphoric effects of opioids. Taken daily by mouth, buprenorphine is considered more effective at keeping people in recovery from drug use than treatment regimens such as twelve-step programs that do not include medication, although experts agree that not enough research has been conducted. 4 It also protects people from succumbing to a deadly overdose if they relapse and start using opioids again. For people attempting to abstain from drugs without medication, the risk of overdose is high because they lose their tolerance for opioids, making even a small dose potentially fatal. In contrast, daily buprenorphine users maintain their tolerance to opioids, making it very unlikely they will overdose if they use illicit drugs again.But in spite of the medical profession’s persistent enthusiasm about buprenorphine’s outcomes, only a small percentage of doctors are prescribing it to help quell the nation’s prescription drug and heroin epidemic.It remains underutilized in part because of stigma against the use of so-called maintenance medications, including methadone, which was approved in 1964 to treat addiction. Buprenorphine and methadone are themselves opioids, leading critics to claim that their use amounts to trading one addiction for another. Although regulated differently, both methadone and buprenorphine are considered controlled substances by the federal government because of their potential for diversion into the black market. But stigma alone doesn’t explain the scarcity of doctors who prescribe buprenorphine. Of the more than 900,000 US physicians who can write prescriptions for highly addictive opioid painkillers, fewer than 4 percent—32,000—have sought a license to prescribe buprenorphine to people who become addicted to the painkillers. 5 The vast majority of doctors with federal permission to prescribe buprenorphine rarely, if ever, use it. As a result, physicians who specialize in buprenorphine treatment and commercial addiction treatment centers typically experience more demand than they can meet. Thousands of people who seek medication-assisted treatment for opioid addictions are put on waiting lists, many for as long as a year. In Vermont, for example, where the American Journal of Public Health reports that the number of doctors with a license to provide buprenorphine should be more than adequate to treat the number of people with addictions, more than 500 people are on waiting lists for addiction medications. 6 In Burlington, thirty-three-year-old Christopher Dezotelle recently waited eighteen months to get into buprenorphine treatment. Like many others in the same situation, he spent hours every day trying to score the medication on the street until his turn came up. Dezotelle had been treated with buprenorphine by a primary care physician in a small town north of Burlington, and it worked well for him for two years. But when he moved into the city for employment, he couldn’t find a physician who would prescribe it.“At this point in my recovery, I still need something,” Dezotelle said. “I’m not okay in my own head. If I’m there too long I’m going to end up in a situation where it’s a decision that’s not really a decision. I’m going to use heroin because it’s so easy to get.”Whether seeking buprenorphine treatment for the first time or returning to treatment after a relapse, which is the norm among people in recovery from opioid use, people who need treatment need it right away. Delaying treatment, LaBelle said, can have devastating consequences: “The most heart wrenching thing in the world is to call someone who has been waiting for treatment for months and hear their mother tell you they died of an overdose.”Federal Response In response to this dramatic underuse of existing medicines in the midst of a deadly epidemic, President Barack Obama has become the first president to promote the wider use of anti-addiction drugs. In its 2017 budget, the Obama administration proposed spending $1.1 billion to help the growing number of opioid-addicted people, primarily by expanding access to buprenorphine. 7 In addition, the Department of Health and Human Services (HHS) in March proposed a rule change that would allow doctors licensed to prescribe buprenorphine to treat more patients. 8The Drug Addiction Treatment Act of 2000 put in place the current system, under which doctors who undergo eight hours of training and register with the Drug Enforcement Agency are licensed to prescribe buprenorphine. Even with that license, however, doctors are limited to serving, at any given time, a maximum of 30 patients in the first year and 100 patients in subsequent years.By setting a limit on the number of patients served, Congress aimed to prevent so-called pill mills in which doctors sell prescriptions for cash without determining whether patients need the medication or intend to use it to treat their addictions. The new rule proposed by HHS would extend the cap to 200 patients at any given time—a level critics say is still too low. The American Society of Addiction Medicine has argued against any “arbitrary limits” on the number of patients a physician can treat. 9 A bill in Congress, the Recovery Enhancement for Addiction Treatment (TREAT) Act, would do away with those limits and allow the nation’s 175,000 nurse practitioners and 92,000 physician assistants to get a license to prescribe buprenorphine as well. Unrealized PotentialIf more primary care providers prescribed buprenorphine, there would be no need for the limited number of physicians who now write scripts for it to serve large numbers of patients, advocates argue.“The dream of primary care doctors prescribing buprenorphine hasn’t really happened,” said Andrew Kolodny, medical director for Phoenix House, a group of treatment centers based in New York. “It’s still a worthwhile dream, and maybe we’ll get there.”But until then, there remains a need to realistically consider other ways to provide treatment to the spiraling number of people who need it. Specialized buprenorphine centers, Kolodny argued, could be set up to provide this important treatment to more patients than busy primary care doctors will ever be able to do.That’s exactly what’s happening in New England’s largest public health hospital and across Massachusetts in community health settings. LaBelle’s team at Boston Medical Center now includes 25 physicians and serves more than 500 patients. “We’re getting ten to twenty new patients every week,” she said. A new study published in the Journal of Substance Abuse Treatment describes how LaBelle used state funding to spread her Nurse Care Manager Model to fourteen federally qualified health centers across the state. 10 These days, LaBelle spends most of her time training clinicians at Boston Medical Center and elsewhere as the health centers expand their buprenorphine operations to meet soaring demand. She also travels around the country presenting the details of her office-based opioid treatment protocol for others interested in emulating it. When the National Institute on Drug Abuse funded the research that led to buprenorphine’s development more than a decade ago, the hope was that office-based prescribing of the drug, which comes in a dissolvable tablet and sublingual film, would mean greater access to addiction medication nationwide. Unlike the use of methadone, patients taking buprenorphine would not have to show up at a specialized clinic every morning to receive their daily dose. They could get a prescription from their family doctor, pick up a month’s supply at a local drugstore, and take the addiction medicine in the privacy of their homes. Advocates and specialists pushed researchers and manufacturers to develop buprenorphine in the hope of medicalizing addiction treatment. Their goal was to enable anyone in need to seek help for the chronic disease of addiction at their local doctor’s office, just as they do for other chronic diseases such as diabetes, hypertension, and heart disease. But in most parts of the country, that hasn’t happened. Fewer than half of the 2.2 million people who need treatment for opioid addiction are receiving it, according to HHS. 11Busy Doctors, Low FeesUntil recently, most people with addictions have had to rely on treatment by specialists outside of mainstream medicine who focus on abstinence, twelve-step programs, and long residential stays to help people beat addictions. This marginalization of addiction treatment—in addition to the fact that most physicians receive no training in addiction during medical school—has served to reinforce the long-standing view of many Americans, including some physicians, that addiction is a moral failing rather than a disease.What is more, providers of addiction services historically have been paid less than the fees providers of other medical and surgical services receive. And until very recently, commercial insurance and Medicaid coverage offered only limited reimbursement for addiction treatment. As a result, there was little incentive for clinicians to pursue training in addiction treatment.That may be changing, however. The Affordable Care Act now requires all insurance providers to cover addiction services as an essential benefit, and more than half of all states have expanded Medicaid to low-income adults, a population with a high prevalence of substance abuse.The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, which requires insurers to pay for addiction and mental health services at the same level paid for other medical and surgical procedures, may also start to bring addiction treatment up to the same standards as the rest of medicine. In the meantime, the dearth of doctors able and willing to prescribe buprenorphine has put thousands of people with addictions at risk. Although doctors cite a variety of reasons for not prescribing the addiction medication, among the most common is concern that without access to behavioral health counseling and other support services such as housing and job training in the community, patients taking buprenorphine are not likely to remain in recovery.Addiction professionals agree that people who take buprenorphine should also receive counseling and other supports to achieve sustained recovery from drug use. But LaBelle and others on the front lines of the opioid epidemic argue that buprenorphine should be initiated as soon as possible, even if counseling isn’t readily available.Kelly Clark, president-elect of the American Society of Addiction Medicine, said the lack of buprenorphine access is particularly severe in many of the nation’s hardest-hit rural areas. The Drug Addiction Treatment Act, the law that allows doctors to prescribe buprenorphine, “has been in effect for sixteen years, and we’ve seen very little uptake in the primary care population for which it was intended,” Clark said.A major reason, she said, is that family doctors—particularly rural sole practitioners and physicians who work in community health centers—are busy caring for people with all kinds of other health problems. Treating people with addictions takes more office time and paperwork than most other conditions and involves “unpleasant conversations with patients that most doctors aren’t prepared to have,” Clark said.Doctors need more support staff to treat addiction patients than is typically affordable in a small primary care practice, Clark explained. LaBelle’s nurse manager model is precisely designed to provide the support doctors need at affordable prices.Nurses In ChargeAs a registered nurse, LaBelle can’t prescribe buprenorphine. But she and other nurses at Boston Medical Center are playing a central role in assessing and treating buprenorphine patients, which has allowed more doctors to engage in treating the growing population of opioid drug users.Expanding the program to community health centers raised the number of physicians prescribing buprenorphine more than fourfold, from 24 at Boston Medical Center to 114 across the commonwealth. Using a collaborative model, nurses and social workers manage the treatment process and conduct most of the office visits. When patients come to a clinic seeking help for their addictions, a nurse on the team checks their urine for opioids and other drugs; talks to them about their drug use and health and mental health history; and makes sure their insurance is up to date and covers the treatment.A nurse explains how buprenorphine works and makes sure the patient isn’t taking benzodiazepines such as Valium or Xanax, which are dangerous when combined with buprenorphine. Nurses and social workers also set patients up with behavioral health counseling and group classes and refer them to mental health professionals when needed.Doctors enter the picture only to prescribe the medication and approve the patient’s treatment plan. Over the course of each patient’s treatment, which typically includes monthly office visits and can last for years, doctors see patients only occasionally.Not long after LaBelle and her colleagues started prescribing buprenorphine in 2003, it became clear that it would require a collaborative model to reach everyone in need. “It’s not rocket science,” LaBelle likes to say. Nurses traditionally have done most of the work in treating other chronic diseases like diabetes. Getting people with opioid addictions started on buprenorphine, maintaining their treatment, and coordinating their counseling is no different, she said.But to set up a bigger team at Boston Medical Center and recreate it in many of the state’s smaller communities would take money. When LaBelle asked the Massachusetts Bureau of Substance Abuse Services to fund the project in 2003, she found a ready and willing partner. The director at the time was Michael Botticelli, now director of the White House Office of National Drug Control Policy. He was already a believer in buprenorphine and methadone for the treatment of opioid addiction and had made funding projects like hers a top priority. Today, Botticelli is still crusading at the national level for greater access to addiction medicines. In April the Obama administration disbursed $94 million in federal grants to be used by community health centers in forty-five states to expand access to opioid addiction treatment in many of the nation’s hardest-hit communities. 12 LaBelle is hopeful that the investment will help other community health centers develop collaborative models similar to hers. Fatal To ChronicToday’s opioid epidemic is sometimes compared to the HIV/AIDS epidemic of the 1980s and 1990s. Kelly Pfeifer of the California Health Care Foundation, which advocates for greater access to treatment, described the similarities as follows. “We had an epidemic in the past with an escalating death rate, and a population we stigmatized and blamed for their disease. Patients were shunned, and treatment was ghettoed,” Pfeifer said, describing the early years of the HIV/AIDS epidemic.Then things changed, Pfeifer said. “Once effective medication was found, and AIDS was treated as a chronic disease, not a character flaw, and treatment was simplified so that a broad population of physicians—not just immune deficiency specialists—could treat HIV, the AIDS death rate plummeted,” she said. By 2002, around the same time drug overdose deaths were beginning to rise significantly, AIDS deaths had fallen from a high of more than 50,000 deaths in 1994 to about 20,000 in 2002. 13 Since then, the toll dropped further to fewer than 5,000 per year and has remained stable ever since. 13 And although many people who need treatment still aren’t getting it, HIV is widely understood today as a serious chronic illness, not a fatal one. “We could do the same thing with opioid addiction,” Pfeifer said. “And we have even more of an obligation to do so, since we, the medical profession, created this epidemic.”NOTES1 Kochanek KD , Xu JQ , Murphy SL , Miniño AM , Kung H-C . Deaths: preliminary data for 2009. National Vital Statistics Reports. Vol. 15, No. 4 . Hyattsville (MD) : National Center for Health Statistics ; 2011 Mar 16 . Google Scholar 2 Rudd R , Aleshire N , Zibbell J , Gladden M . Increases in drug and opioid overdose deaths—United States, 2000–2014 . MMWR Weekly Report [serial online]. 2016 Jan 1 ; 64 ( 50 ): 1378 – 82 [cited 2016 May 5 ]. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm?s_cid=mm6450a3_w Google Scholar 3 National Center for Health Statistics . Wide-ranging Online Data for Epidemiologic Research (WONDER) [home page on the Internet]. Hyattsville (MD) : NCHS ; 2016 [cited 2016 May 5 ]. Available from: http://wonder.cdc.gov Google Scholar 4 Weiss RD , Potter JS , Fiellin DA , Byrne M , Connery HS , Dickinson W , et al. Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase randomized controlled trial . Arch Gen Psychiatry . 2011 ; 68 ( 12 ): 1238 – 46 . Crossref, Medline, Google Scholar 5 Substance Abuse and Mental Health Services Administration . A breakdown of U.S. DATA-certified physicians providing buprenorphine treatment [Internet]. Rockville (MD) : SAMHSA ; [last updated 2015 Dec 2; cited 2016 April 21 ]. Available from: http://www.samhsa.gov/programs-campaigns/medication-assisted-treatment/physician-program-data Google Scholar 6 Jones C , Campopiano M , Baldwin G , McCance-Katz E . National and state treatment need and capacity for opioid agonist medication-assisted treatment . Am J Public Health . 2015 ; 105 ( 8 ): e55 – 63 . Crossref, Medline, Google Scholar 7 White House [Internet]. Washington (DC) : White House . Press release, Fact Sheet, President Obama proposes $1.1 billion in new funding to address the prescription opioid abuse and heroin use epidemic . 2016 Feb 2 [cited 2016 May 5 ]. Available from: https://www.whitehouse.gov/the-press-office/2016/02/02/president-obama-proposes-11-billion-new-funding-address-prescription Google Scholar 8 Department of Health and Human Services [Internet]. Washington (DC) : HHS . Press release, Fact Sheet: medication assisted treatment for opioid use disorders: increasing the buprenorphine patient limit . 2016 Mar 29 [cited 2016 Apr 21 ]. Available from: http://www.hhs.gov/about/news/2016/03/29/fact-sheet-mat-opioid-use-disorders-increasing-buprenorphine-patient-limit.html# Google Scholar 9 American Society of Addiction Medicine . Public policy statement on pharmacological therapies for opioid use disorder . Chevy Chase (MD) ; ASAM ; 2013 Apr 24 ; [cited 2016 April 21 ]. Available from: http://www.asam.org/docs/default-source/public-policy-statements/pharmacological-therapies-for-opioid-use-disorder-2013-04-24.pdf?sfvrsn=4 Google Scholar 10 LaBelle CT , Han SC , Bergeron A , Samet JH . Office-based opioid treatment with buprenorphine (OBOT-B): statewide implementation of the Massachusetts Collaborative Care Model in community health centers . J Subst Abuse Treat . 2016 ; 60 : 6 – 13 . Crossref, Medline, Google Scholar 11 Sullivan P . White House to request $1 billion to counter drug abuse epidemic . The Hill [serial on the Internet]. 2016 Feb 2 [cited 2016 May 5 ]. Available from: http://thehill.com/policy/healthcare/267895-white-house-proposes-1-billion-to-fight-opioid-epidemic Google Scholar 12 Department of Health and Human Services [Internet]. Washington (DC) : HHS . Press release, HHS awards $94 million to health centers to help treat the prescription opioid abuse and heroin epidemic in America ; 2016 Mar 11 [cited 2016 Apr 21 ]. Available from: http://www.hhs.gov/about/news/2016/03/11/hhs-awards-94-million-to-health-centers.html Google Scholar 13 Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention . Mortality slide series [Internet]. Atlanta (GA) : CDC ; [cited 2016 May 10 ]. Available from: http://www.cdc.gov/hiv/pdf/statistics_surveillance_hiv_mortality.pdf Google Scholar Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article MetricsCitations: Crossref 10 History Published online 1 June 2016 Information Project HOPE—The People-to-People Health Foundation, Inc. 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