By Rocco A. Iannucci, MD

chairs at treatment center

Getting treatment for an opioid use disorder will hopefully in turn reduce the number of overdoses and deaths related to opioid use.

Despite increased public awareness about the dangers of opioids, the epidemic continues in the US. What can we do to counter this deadly trend?

The numbers are striking.

• About 68% (more than 47,000) of the more than 70,200 drug overdose deaths in the US in 2017 involved an opioid
• 36% of those 47,000+ deaths were attributed to prescription opioids
• In 2017, the number of overdose deaths in the US involving opioids prescription and illegal—was 6 times higher than in 1999
• On average, 130 Americans die every day from an opioid overdose

Increased attention to deaths related to opiate use has spurred action. Many states have developed mandates to intervene to prevent deaths. There also has been increased response to the need for more caution in the prescribing of opioids.

We are in the middle of an epidemic, with hundreds of people losing their lives every day,” said Shelly F. Greenfield, MD, MPH. “But we are fighting each day to develop tools and policies that will stem the loss of life.” Greenfield is the director of McLean’s Alcohol and Drug Abuse Clinical and Health Services Research Program.

Improving Reaction to Emergencies
Public health advocates and clinicians have embraced the use of naloxone for opioid use emergencies. Trained laypersons can administer this opiates antidote. Partly through the intervention of the FDA, over time, prices for naloxone treatments have been greatly reduced.

Recently, distribution of intranasal naloxone to those struggling with opiate addiction—and to their loved ones—has become an overdose prevention strategy. Intranasal naloxone can be administered by anyone. This can revive an overdosed individual while formal medical treatment is sought.

Getting to the Root of the Problem
Intranasal naloxone is an important and potentially lifesaving intervention for someone who has overdosed on opiates. Nonetheless, it is not a substitute for addressing the underlying problem of addiction.

Hilary S. Connery, MD, PhD, is the clinical director of McLean’s Substance Use Disorder Division. She is working to enhance follow-up care for those who have received emergency treatment for opioid use.

“A lot of patients who get naloxone rescue don’t engage in followup treatment,” she said. “Obviously, opioid use disorder is a lethal illness, but it’s a lethal illness for which we have very good treatment that will save lives. It’s time to create a community-wide collaborative where rapid response and rapid initiation of treatment are available to patients, post-overdose, for all who are willing to seek treatment and are open to that.”

Getting treatment for an opioid use disorder will hopefully in turn reduce the number of overdoses and deaths related to opioid use.

Treating Opioid Use Disorders with Medication

Many evidence-based treatments now exist. These include medication based and therapeutic approaches to treat substance addiction.

Methadone is one type of medication that can be effective for opioid use disorders. It stimulates pain-relieving receptors in the brain similarly to other opiates, such as oxycodone.

There’s an important difference between methadone and opioids that are often misused, like heroin. Methadone’s effect takes place more slowly and lasts longer. As a result, people in treatment with methadone typically do not experience a euphoric “high,” nor do they experience the cravings associated with the drug effect wearing off quickly.

Studies have demonstrated that methadone treatment is associated with a lower risk of opioid misuse, death, criminal activity, and unsafe behaviors that can lead to infection with HIV or viral hepatitis.

Methadone use is highly regulated. It only takes place at specially licensed treatment programs that offer intensive treatment. This approach may reduce the risk of patients using medication for nontreatment purposes. It can also be an obstacle to people who want to be treated, but don’t want to go to a methadone treatment program.

Buprenorphine was introduced, in part, to offer an office-based treatment option for patients. Like methadone, it stimulates the opiate receptor in the brain to reduce drug cravings. It also blocks the opiate receptor to reduce or eliminate the effects of misused opiates. Buprenorphine treatment has similar benefits to moderate doses of methadone, in terms of reducing opiate use and mortality rates.

Buprenorphine is commonly taken as a pill placed under the tongue. A new, long-acting version can be injected monthly to help individuals stick to the treatment and to maintain steady blood levels.

Unlike methadone, clinicians who have completed specialty training can prescribe buprenorphine. This allows people to receive a prescription in their community provider’s office. Many people find this preferable and more convenient than treatment at a methadone program.

About 68% (more than 47,000) of the more than 70,200 drug overdose deaths in the US in 2017 involved an opioid. 36% of those 47,000+ deaths were attributed to prescription opioids

A third medication option is naltrexone. It is a blocker of the opiate receptor. This means that it reduces or eliminates the effects of other opiates by not allowing them to stimulate the brain’s opiate receptor.

Naltrexone for opioid use disorder is most commonly administered as a long-acting, monthly injection. This helps reduce vulnerability to relapse when a person might skip a daily dose. Long-acting,injectable naltrexone treatment is associated with similar reductions in opiate use to those seen with buprenorphine treatment.

One challenge with naltrexone treatment is the need to establish an opioid-free period of 1-4 weeks before taking the first dose. This can be an overwhelming obstacle for many people struggling with opioid use disorder—unless they are provided with adequate support.

Inpatient and residential treatment programs can provide a structured setting for detoxification and stabilization before starting medication treatment. Residential treatment for opioid use disorders is associated with less use of heroin and other drugs, lower rates of heroin dependence, fewer injection-related health problems, reduced involvement with crime, and improved overall health. There is also strong scientific evidence of benefit from particular forms of talk and behavioral therapies delivered by well-trained clinicians.

Policy around the country regarding treatment is starting to change. In Massachusetts, for example, collaborative efforts between the Baker Administration and state legislators have increased patient access to residential treatment. It is important for people struggling with opioid use disorder to recognize that they may now be able to access treatment with insurance support.

Struggling with Multiple Conditions

People with opioid use disorder are at very high risk of suffering from depression—five times more than people without opioid use disorders. They are also at increased risk of death by suicide. This is partly due to the very high occurrence of depression and other mental health conditions seen among those with opioid use disorders.

Clinicians offer a broad array of options that have been proven to help with these common but serious conditions. These treatments may include different types of medications and therapy.

Overcoming the Stigma of Addiction

Effective interventions are too frequently underutilized. This is often related to a belief that addiction represents a failure of willpower or a flaw in character.

Most genetic studies of drug and alcohol use disorders reveal that at least 50% of the risk for these conditions is heritable. This means that it can be passed on in families, like eye color or diabetes. This argues for a strong biological basis for these chronic diseases, calling for clinical treatment based on best medical practices.

People do not die of character flaws. They die of illnesses. If you or a loved one is struggling with addiction to drugs or alcohol, speak to your own or your loved one’s physician, or consult one of these resources:

National Institute on Drug Abuse: Information for patients and families
• SAMHSA’s Behavioral Health Treatment Services Locator
• McLean Hospital addiction treatment programs
• SAMHSA’s National Helpline: 1.800.662.HELP

Rocco A. Iannucci, MD, is the program director of Fernside, a McLean Hospital Signature Addiction Recovery Program. He is also an instructor in psychiatry at Harvard Medical School. Dr. Iannucci specializes in the treatment of people with severe substance use disorders and those with multiple mental health conditions. He has published on the treatment of addiction in residential programs, and on cocaine misuse.