Friday Feb 09, 2018
A Right Way to Treat Opioid Addiction
A little more than a year ago, I wrote a post for this blog titled "Prescribing for Opioid Addiction is My Responsibility." I received positive feedback for this story about my professional transition from avoiding obtaining a waiver to prescribe buprenorphine for medication-assisted therapy to feeling a responsibility to my patients and society for doing so.
My actions were based in part on my long-term view of family medicine as being community-oriented. With that perspective, I have a responsibility not only to the patients in my exam room, but also to all people in my area.
There were numerous responses to that post, many agreeing with my perspective, but not all. One of the most common questions was, "Aren't we just replacing one addiction (prescription or illicit opioid) for another (buprenorphine)?" Another comment was that some people on buprenorphine still use other opioids, particularly street drugs.
The New York Times recently published an excellent opinion article by Maia Szalavitz, a reporter and author who focuses on science, public policy and addiction treatment. Her article, "The Wrong Way to Treat Opioid Addiction,"(www.nytimes.com) addressed both of these concerns, including the problems with programs that require abstinence without medication.
The definition of addiction as a chronic brain disease is twofold: having adverse effects on mental and physical health, and a loss of control over behavior. In other words, compulsive use despite negative health and social effects. The results of this compulsive seeking often leads to broken marriages and families, loss of employment, legal troubles and loss of social standing, all due to the ongoing need to obtain the substance.
Let's clarify: Addiction is not the need for a drug to avoid being physically ill. Under that definition, fluoxetine, insulin and other legal medications would be considered addictive. Using fluoxetine or insulin in the same or medically adjusted doses daily may be considered physical dependence by some, but it certainly does not lead to the social consequences of alcohol, heroin or prescription opioids when misused.
The same is true for buprenorphine. Probably the most important benefit of Suboxone and Subutex or some of the new formulations is that these medications prevent the withdrawal symptoms that lead people who are addicted to seek more of the illicit drug. A person on buprenorphine is not in withdrawal, not intoxicated, not craving, not seeking and, most importantly, is free to return to a normal life. If some wish to call this an addiction rather than treatment, I suggest that they reconsider that characterization.
As to some patients in medication-assisted treatment relapsing, Szalavitz succinctly writes, "Medication reduces relapse more than abstinence does -- but relapse is still common … In abstinence treatment, however, relapsers drop out and are invisible; with medication, they often remain in treatment. And remaining in treatment is important because it cuts overdose risk, even during relapse. Many highly traumatized people also need the continued health care support before they are able to quit street drugs."
People who are addicted to heroin and other opioids reduce their risk of dying when they are treated with buprenorphine or methadone. I am glad that, in the time since I wrote the earlier post, more and more family physicians, other non-addiction specialist clinicians and health care organizations are obtaining waivers and providing medication-assisted treatment.
In my county, there is a project called Safe Communities(safercommunity.net) with professionals from many backgrounds working on multiple paths to decrease the epidemic of opioid overdoses and deaths. Medication-assisted treatment is part of that effort, and I hope your community has something similar. If not, please work to ensure your community has adequate access to this life-saving treatment even if you do not prescribe it yourself. In that way, we will reach more people in need than just the next one in the exam room.
Alan Schwartzstein, M.D., is the speaker of the AAFP Congress of Delegates.
Posted at 12:33PM Feb 09, 2018 by Alan Schwartzstein, M.D.