Jacqueline Filis, the program’s executive director, explains that heroin is the substance most commonly abused by the majority of those who seek our assistance. Initially, it was a gradual increase, but beginning in 2013, it accelerated.
Twenty percent more of patients are dependent on prescription opioids. Currently, slightly more than half of our patients are admitted due to the opioid epidemic, according to Filis.
In 2014, the epidemic caused more than 27,000 overdose deaths in the United States, raising new questions about how to best combat opiate addiction, which, according to researchers, is more difficult to overcome than most other types of addiction.
Decades ago, treatment centered on an abstinence-only approach consisting of detox and rehabilitation, accompanied by counseling or group therapy, many of which were influenced by the 12-step model. As the number of fatalities has increased, however, many experts have begun to rethink this approach, arguing that opiate addiction should be treated similarly to a chronic illness such as diabetes or depression. According to them, abstinence and counseling are insufficient. In addition, medication must be an option.
The methadone alternative
Despite this change, such treatment can be difficult to locate. 9 percent of the 14,148 facilities included in the National Survey of Substance Abuse Treatment Services offered medication-assisted treatment for opioid addiction in 2013.
When medication is available, methadone is the oldest and cheapest option. Methadone, which was introduced in the 1960s, can help a user combat cravings and withdrawal symptoms. Additionally, it can block the effects of any heroin a patient may use during treatment.
However, because methadone can produce a milder version of the high that heroin patients experience, it may be diverted to the street and abused. Due to this risk, individuals on methadone maintenance therapy must visit a clinic every day to receive a methadone dose under medical supervision. According to the Pew Charitable Trusts, there are approximately 1,400 clinics licensed to dispense methadone throughout the United States. However, the majority of these clinics are located in urban areas, making access difficult for those living in suburban or rural areas.
Some people have been taking methadone for years and are able to function normally, but because it is a narcotic, the treatment can be stigmatized.
According to Dr. Andrew Kolodny, a senior scientist at The Heller School of Social Policy and Management at Brandeis University, there is a perception that treating opioid addiction with opioid medication is not treatment, that it is simply substituting one drug for another, and that a person should not be considered clean or abstinent while taking this medication.
According to Dr. Mary Jeanne Kreek of Rockefeller University, methadone quickly acquired a stigma. In the 1960s, Kreek was a member of the team that investigated methadone as a potential treatment for opioid addiction. She notes that although methadone clinics are governed by stringent regulations, some communities continue to shun them.
Here in New York City, the number of methadone clinics has decreased, not increased. Why? Stigma. Why? They generate no revenue. Why? Not on my property.
When the Staten Island YMCA began investigating the most effective methods for treating heroin addiction, there was initial resistance to buprenorphine, a medication that has proven effective.
According to Filis, there was resistance even within our own staff. Five years later, according to her, the mentality has shifted. As long as you are not abusing buprenorphine, we consider you to be sober.
While methadone can be used for all levels of dependence, research suggests that buprenorphine may be the best option for those with mild to moderate dependence, as it carries a lower overdose risk. Buprenorphine, like methadone, is a narcotic that can be crushed, snorted, or injected to achieve a high; therefore, it is frequently combined with naloxone, a drug carried by first responders to reverse opioid overdoses. This combination is most commonly marketed as Suboxone, a sublingual film that dissolves slowly and is less likely to be abused because naloxone induces withdrawal symptoms.
In contrast to methadone, buprenorphine and buprenorphine-naloxone are deemed safe enough to be prescribed by a physician and taken at home. As opioid and heroin addiction has shifted from major cities to rural areas, buprenorphine has been suggested as a potential treatment option for those who reside too far from methadone clinics.
There are two major obstacles for patients attempting to obtain buprenorphine or buprenorphine-naloxone. Physicians must first obtain a waiver from the Drug Enforcement Administration before prescribing either substance. Once physicians obtain the waiver, the federal government limits the number of patients for whom they can write prescriptions to 30 in the first year and 100 in subsequent years. Even if a doctor has a waiver, many are hesitant to prescribe, according to Kolodny, resulting in lengthy waiting lists.
According to federal data, slightly fewer than 32,000 physicians currently have waivers to prescribe buprenorphine, with nearly 70% certified to treat 30 patients and the remaining 30% permitted to treat 100. Currently, there are no restrictions on prescribing opioid analgesics. Doctors wrote 259 million prescriptions for opioid analgesics in 2012.
The drugs that can cause this problem do not have reasonable limits, Kolodny says, and we have, in my opinion, excessive barriers to a safer drug, which may be one of the only ways out of this mess.
This week, the National Governors Association called for painkiller prescribing training, drug monitoring, and prescription limits to combat overprescribing. In the same statement, they called for the elimination of federal barriers preventing physicians from prescribing buprenorphine.
Naltrexone and Vivitrol
In 2010, the Food and Drug Administration approved Vivitrol, a long-acting injection for the treatment of opioid addiction. It is a tablet form of naltrexone, which was already used to treat alcoholism.
Naltrexone is not a controlled substance, so there is no risk of abuse. It blocks the effects of heroin and opioids, but can only be administered to detoxified patients. As opposed to methadone and buprenorphine, which must be taken daily, it is popular in drug courts and prisons and only needs to be injected once per month. One disadvantage is the injection’s $1,000 price tag.
Rebecca Hogamier, director of the Division of Behavioral Health Services for the Washington County Health Department in Maryland, encounters numerous opiate and heroin-dependent individuals who have been incarcerated. She oversees a treatment program that provides both buprenorphine and Vivitrol.
If someone is not using opiates on a daily basis and can abstain from opiates for 10 days, Vivitrol will be administered, according to Hogamier. Our greatest achievement has been starting inmates in jail on Vivitrol, as they are now clean.
After being released from prison, individuals are required by the court to attend treatment. Prior to the program’s implementation of Vivitrol, according to Hogamier, only fifty percent participated. After the injections began, 75% of patients showed up for treatment. She reports that approximately 80% of those given Vivitrol remained in treatment longer.
However, these numbers have not been sufficient to convince everyone. While naltrexone and Vivitrol have been approved for the treatment of alcoholism, experts such as Kreek claim there is less evidence of their efficacy in treating opioid addiction.
According to Kreek, it does not harm anyone who is an alcoholic. However, opiate addicts have a relative lack of endorphins. Using [naltrexone or Vivitrol] to block their opiate receptors makes them feel awful 24 hours a day.
Kolodny says that Vivitrol is probably an appropriate treatment for someone who has not been addicted to nicotine for a very long time and who lives in a highly controlled environment. But particularly for heroin injectors, dropout rates are high, and patients do not adhere to treatment. According to Kolodny, this increases their risk of overdose in the event of a relapse.
According to Hogamier, anyone who has completed detox is at a greater risk of overdosing. Not only Vivitrol, but anyone with a period of abstinence is affected.
Experts agree that there is no cure for addiction. Methadone, buprenorphine, and naltrexone provide addicts with space, control, and relative normalcy in their lives, allowing them to engage in counseling, behavioral therapy, and support groups to treat their addiction. According to research, those who receive medication and counseling are more likely to remain in treatment and have a lower relapse risk.
Treatment is a personal decision; what works for some individuals may not work for others. A person’s choice of treatment may be influenced by availability to a certain extent. Moreover, insurance can be a deciding factor. Occasionally Medicaid, Medicare, or private insurance will cover substance abuse treatment, but it is often difficult to obtain coverage.
According to Dr. Melinda Campopiano, a medical officer at the federal Substance Abuse and Mental Health Services Administration, a patient may choose the medication that is least likely to interact with other medications they are taking. She notes, however, that one of the greatest barriers to treatment, above and beyond effectiveness, cost, and stigma, is that many individuals who require treatment are not yet prepared to seek it.
The heroin and opioid epidemic in America has raised questions about how to effectively treat addiction. Many now say medication should be offered alongside counseling.