MEDICATION ASSISTED TREATMENT for OPIATE ADDICTION How do they work, are they effective are they expensive? Why should we care?

Why is effective opioid addiction treatment so important today? Approximately 64,000 Americans died from drug overdoses in 2016 – about the same number of soldiers who died in Viet Nam, Iraq and Afghanistan wars combined. In Philadelphia in 2016 there were 907 overdose deaths, by 2017 that number had increased to 1200 deaths from an overdose. Compare those numbers to the 277 and 312 homicide deaths recorded in 2016 and 2017 respectively. We focus on the homicide deaths – they are more shocking and news worthy. The drugs responsible include heroin, fentanyl, oxycodone, hydrocodone, benzodiazepines and cocaine. Most frequently in deadly combinations. Each opioid death was responsible for 12 ED visits. The cost of treating overdose victims in the hospital ICU was $92,408 in 2016 – increasing from $58,517 in 2009. Until very recently the ACA covered most of those costs. However, with the repeal of the individual mandate these costs will have to be shouldered by the hospital systems.

The total cost associated with prescription opioid use disorders and over doses in the United States has gone from $29.1 billion dollars in 2001 to $115 billion dollars in 2017. Including alcohol abuse and that total goes to over $600 billion dollars. The aggregate cost in those years is estimated to be over $1 trillion dollars. These costs include lost wages, lost productivity, increased healthcare costs, lost tax revenues and increased as well as additional spending on health care, social services and criminal justice. Despite all of the accusations, blame placing and hand wringing very little of the total is spent on treatment. Declaring a federal emergency without the necessary funds to expand prevention, treatment and research opportunities and help to de-stigmatize this disease will predictably do little good. What do we have going positively? Currently there are three primary drugs and several alternative formulations that have proven effective in treating opioid use disorders in the context of Medication Assisted Treatment (MAT). They are classified as:

Opioid Agonists, Partial Agonists and Opioid Antagonists Methadone (agonist) and Buprenorphine (partial agonist) are medications that reduce the negative effects of craving and withdrawal; thereby supporting recovery. They can support the individual who has detoxified from heroin or prescription opiates by not producing the euphoria anticipated in a potential relapse situation or expected by an addicted person. Methadone must be dispensed, generally on a daily schedule, through a state licensed, DEA approved opioid treatment program. The cost of methadone treatment is $6552 per year. Buprenorphine, a partial opioid agonist is available in tablet or sublingual film. It can be dispensed in an office visit by prescription from a certified physician. FDA has approved a once monthly injection and a 6 month subdermal implant for those individuals already stabilized on buprenorphine. The cost of treatment with buprenorphine is $5980 per year

Naltrexone (antagonist) blocks the activation of opioid receptors in the brain. Rather than controlling withdrawal and craving it treats addiction by preventing any opioid from producing rewarding effects such as euphoria. Patients often complained about its effectiveness and adherence was poor. Recently a long acting injectable form of naltrexone that was brought to market to treat alcohol use disorders – Vivitrol - has now been approved to treat opioid addiction. The cost for treatment with injected naltrexone is $14,112 per year. Unfortunately, potential patients have to be withdrawn from all opiates if they are to avoid withdrawal symptoms. In perspective: The annual cost for those individuals being treated for other chronic conditions such as diabetes mellitus is $3560. For patients with kidney disease the cost is $5624 per year. Unfortunately the stigma of addiction prevents a rational view of how it should be treated.

Recent additions include: Naloxone is similar to naltrexone but is a complete opiate antagonist. It is used primarily to immediately reverse the overdose effects of an opioid and as such is used primarily in emergency situations. It has been widely distributed to EMTs, police and fire department first responders. In fact it is so effective that in a U.S. Surgeon General advisory he called on Americans to carry and learn to use naloxone to help prevent overdose deaths. Recent additions include: Probuphine is a six month buprenorphine implant that has recently been recently approved by the FDA Sublocade is a recently approved injectable formulation of buprenophine. This has several advantages: it requires monthly medical staff contact, it eliminates diversion, and is released slowly over a month. Currently medication/vaccine development are very strongly encouraged by the government and pharmaceutical companies.

Regardless of the medication used, time spent as an addict will almost invariably have had emotional/behavioral/psychological/physical effects. Access to safe housing, medical care and counseling/therapy services should be seen as mandated components of a treatment regimen. Governments at all levels frequently stigmatize the addict, under fund treatment, over fund law enforcement efforts. Thereby allowing, if not endorsing a Not In My Backyard (NIMBY) approach to actively block additional treatment programming. This is a common response even if patients are from the same neighborhood. Unfortunately the “climate” for behavioral health care in the US is still generated more by politics and less by need. The local politics involved in treating addiction and mental health issues is often very nasty and counterproductive.