Opioid dependence

From “Improving Care for Hospitalized, Opioid-Dependent Patients: A Promising Start,” by Margot Kushel (JAMA Internal Medicine):

There are 2 evidence-based treatments for opioid addiction: methadone and buprenorphine. Both of these opioid agonists have been reported to markedly reduce morbidity and mortality. The requirement that methadone be dispensed in hospitals or certified methadone clinics has limited its availability, created a stigma for patients, and separated the treatment of opioid addiction from general medical care. The Drug Addiction Treatment Act of 2000 allowed physicians, on completion of a short training course, to prescribe buprenorphine for the treatment of opioid use disorders. By creating an avenue for office-based opioid treatment, the Drug Addiction Treatment Act allowed for the expansion of opioid agonist therapy (OAT) and the integration of opioid addiction treatment into primary care. For patients, this has the benefit of increasing access and reducing the stigma associated with OAT.

Buprenorphine enables primary care physicians to manage opioid addiction as a chronic disease. In a consensus statement, the American Society of Addiction Medicine stated that the “optimum duration of maintenance is unclear, but may involve lifelong use…similar to other chronic diseases such as diabetes or hypertension.” The full potential of engaging individuals who struggle with opioid abuse disorders into treatment has not been realized. There are multiple structural barriers to engaging those who want it into treatment, including a reluctance of physicians to become buprenorphine prescribers, lack of counseling resources, financial barriers, and regulations for physicians, including additional training requirements and limits on the numbers of patients for whom physicians can prescribe buprenorphine. In addition, there are many wasted opportunities to engage those who need it in OAT. We have learned from other health behaviors, such as tobacco use and risky drinking, that health care professionals’ provision of routine screening and referral to treatment can reduce use and improve outcomes. Not using every health care encounter to intervene with opioid addiction, considering its morbidity and the existence of effective treatment, represents a lost opportunity.

The issues I’ve emphasized in bold above are among those that arose at the recent meeting of the Comparative Effectiveness Public Advisory Council, which focused on opioid dependence. I’ll write more about that meeting after the final report is published.

Kushel goes on to summarize results from a recent study on the effects of buprenorphine administration during hospitalization with linkage to outpatient treatment. Also recently published in JAMA Internal Medicine is a research letter on pain and opioid use by U.S. soldiers after deployment and a related commentary.


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