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Opioid Abuse Treatment Medications Underused

Head in hands

(Photo by Cristian Newman on Unsplash)

20 Sept. 2019. While three medications for opioid abuse are approved by the Food and Drug Administration, the treatments are used sparingly in therapy according to a new review of data. Findings from a team at the Mayo Clinic in Rochester, Minnesota and Washington University in St. Louis appear in yesterday’s issue of the journal Mayo Clinic Proceedings.

The number of drug overdose deaths from opioid abuse continues to grow in the U.S. According to Centers for Disease Control and Prevention, or CDC, more than 702,000 Americans died from a drug overdose between 1999 and 2017, with more than 70,000 deaths occurring in 2017 alone. About two-thirds of those deaths (68%) involved a prescription or illicit opioid.

Researchers led by Tyler Oesterle, medical director of the Mayo Clinic Fountain Centers — the Clinic’s provider of substance abuse and addiction treatments — reviewed the extent to which practitioners are making use of medication-assisted therapies in treating opioid addiction. In fact, three federal agencies in the U.S. — CDC, National Institute of Drug Abuse, and Substance Abuse and Mental Health Services Administration — recommend adding medication therapies to psychotherapy and counseling-based treatment programs.

For its part, FDA so far approved three medications for opioid-abuse therapy programs: naltrexone, buprenorphine, and methadone. Yet, according to estimates by the authors, only about 11 percent of individuals with opioid use disorder are prescribed these medications.

Oesterle and colleagues note that no single medication is ideal for all opioid-abuse patients, and discuss the pros and cons of each drug. Naltrexone works by blocking opioid receptors and acts as a deterrent to further opioid use. If taken as intended, naltrexone can increase the chance for sobriety and reduce the risk of overdose. The problem with naltrexone is that it requires complete abstinence from opioids, and any reduction in compliance with treatments or break in abstinence can trigger a relapse.

Buprenorphine is a semi-synthetic opioid that satisfies the addiction cravings from opioids without creating the pleasurable intoxication. Users of this treatment report high compliance, as well as fewer overdoses and reduced crime. But it requires dosing in a doctor’s office or therapy site, and close monitoring, which reduces its utility for some patients. Abuse of buprenorphine is also a risk, thus its modest use and need for close scrutiny.

Methadone is a maintenance drug approved for heroin addiction treatment programs, and in liquid form is relatively low in cost. Results show methadone maintenance reduces overdose deaths, criminality, and spread of infectious diseases, including HIV, when sharing needles. Methadone compounds last longer in the body, and as a result increase the risk of accidental overdose. In addition, diversion of methadone to street use is a continuing risk.

To encourage more use of mediation-assisted treatments for opioid use disorder, the authors provide a structured decision flowchart for guiding clinicians to recommend an appropriate medication-assisted treatment for patients, after the initial screening. The researchers also call attention to special considerations, including pregnancy, age of the individual, and if the patient needs surgery or is in pain.

The authors conclude that the U.S. and other countries continue to face problems of opioid abuse because of overzealous prescription of the drugs, their wide availability, and the expectation that all pain can be eliminated. “We clearly cannot medicate our way out of the problem,” says Oesterle in a Mayo Clinic statement, “but we have the opportunity to mediate the problem through more judicious use of prescription opioids.”

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