THE OPIOID ADDICTION crisis in the United States has prompted leaders at the state and federal level to promise more money, new laws, and greater focus on the problem. That focus is needed but so far the policy goals lack clear definition. Even as attention on the problem has ramped up, we have continued to treat addiction in ways that have historically not worked well. Doing more of something that’s not working will not correct the problem. If the policy goal is to create treatment interventions that reduce abuse, lower the rate of remission, and restore patients as much as possible to normal living, there is extensive medical research and practical clinical experience suggesting medication-assisted treatment, or MAT, is the way to go.
Aside from emergencies, traditional addiction treatment in the United States is often not medical in nature but guided by the principles derived from 12-step programs. The goal of these programs, which are characterized by admirable spiritual and moral ideals, is complete abstinence driven by self-discipline and support from peer groups. This approach does not work well for people with opioid dependence. As long ago as 1997, National Institutes of Health experts concluded that “opioid addiction is a treatable medical disorder and explicitly rejected notions that addiction is self-induced or a failure of willpower.” The approach recommended by the National Institutes of Health and virtually all other medical and scientific sources is medication-assisted treatment.
Medication-assisted treatment means using one or more pharmacological agents to relieve the symptoms and risks of addiction, enabling patients to begin returning to normal life and to benefit from other behavioral therapies. The treatment is not a magic bullet and medication-assisted treatment does not guarantee success, but it has a substantially higher rate of positive outcomes than traditional non-medical treatment programs. A team of physicians writing in the New England Journal of Medicine likened medication-assisted treatment to the care needed for “other chronic diseases such as diabetes and hypertension,” where “effective treatment and functional recovery are possible.”
Because of the stigma associated with drug abuse and the traditional stereotype of the addict, some people find it counter-intuitive to use medication to treat addiction. But when scientists explain how the brain responds to the excessive use of heroin or pain pills, the logic of addressing the pathology with an appropriate medication is persuasive. Opioids attach themselves to receptors in the brain and artificially generate excessive quantities of the neurotransmitter dopamine, producing feelings of euphoria. Addiction is the result of the brain “learning” this new behavior through excessive repetition until it becomes dependent on the artificial effect and craves more.
The argument that experts make for medication-assisted treatment is that managing the brain’s new habit and mitigating the effects of withdrawal will not happen just because a person wants to stop abusing opioids. The process requires a kind of neurological reverse-engineering that can relieve the brain’s urgent need for more drugs. In the absence of appropriate medication, a significant majority of addicts who go through short-term detox will relapse, often multiple times.
There are three medications used in treating opioid addiction. The best known is methadone, which was initially developed in the 1940s as a pain reliever. Because it works by changing the way the brain perceives physical and psychological pain, methadone was soon used to provide people dependent on heroin with a way to manage their withdrawal and to stabilize their lives. Methadone is a synthetic opioid although it does not produce the same high as abused opioids. It is effective but often poorly perceived in the wider community because of its long association with heroin and because people suffering from an addiction disorder normally must go to a registered clinic daily to receive their dosage.
A second medication, buprenorphine, is now gaining wider acceptance among experts. Buprenorphine is called a “partial agonist,” which means that it activates the same receptors as abused opioids but produces a much weaker effect. Essentially the brain is fooled into believing that its opioid craving is met but this happens without the pattern of withdrawal and euphoria that is typical of addiction. The medication is delivered via a daily pill or a strip placed under the tongue and can be prescribed by physicians who have special authorization and training. Patients normally have a month’s supply to take at home. The most common form of this medication, sold under the trade name Suboxone, has a second element that causes unpleasant symptoms in a patient who relapses and takes another opioid.
The third current option is called naltrexone, sold under the trade name Vivitrol. This is an “antagonist” medication that works in a different way than buprenorphine. Instead of fooling the brain receptors, it blocks them so that a patient who relapses cannot trigger those receptors and experience a high. It is administered by monthly injection and can only be given to patients who are already completely detoxed. Vivitrol is increasingly used in criminal justice settings, particularly for previously addicted inmates who will shortly return to their communities.
Each medication has various dosages, side-effects, advantages, and disadvantages depending on the condition of the patient and the arc of his or her addiction history. Only a physician who fully understands the patient’s needs, matches them to the characteristics of the medications, and carefully monitors the ongoing results should make the decision about how best to exploit medication-assisted treatment for the benefit of individuals who need it. Many patients also need to receive psychosocial counseling to help them build on the opportunity provided by the medication.
The National Institute on Drug Abuse summarizes the available research by concluding that medication-assisted treatment has multiple advantages over other forms of treatment and “decreases opioid use, opioid-related overdose deaths, criminal activity, and infectious disease transmission.” Further, MAT “increases social functioning and retention in treatment.” One important study, a randomized, controlled trial published in 2015 by a researcher associated with Harvard Medical School and McLean Hospital, demonstrated that MAT “at least doubles rates of opioid-abstinence” compared with other forms of treatment.
Unfortunately, the treatment endorsed by experts as offering the highest probability of success in moderating the impact of the opioid crisis is not widely available. A health care system normally driven by evidence of clinical efficacy has not organized itself to deliver the care needed by the millions of Americans who suffer from opioid-use disorder. A report issued by the Pew Charitable Trust found a “treatment gap” in which only 23 percent of publicly funded addiction treatment programs and less than half of private sector programs offer MAT. This lack of availability was attributed to inadequate funding and a dearth of qualified providers.
There are additional reasons for the gap. One is the persistent opinion that relying on medication to treat addiction is a morally compromised approach. A psychologist writing last year in Psychology Today articulated this view by saying that “recovery should be about breaking free from all substances.” He also raised the so-called crutch argument, asking if MAT isn’t simply “transferring from one drug to another.” According to this line of thinking, using any drug to aid in treatment is simply switching dependency from one substance to another and is a sign of weakness. This perspective rejects the analogy that using medication to treat addiction is like using insulin to treat diabetes.
It is a sad commentary on our approach to opioids that addicts have easy access to quality medical care when they overdose but not before. According to the Centers for Disease Control and Prevention, more than 1,000 people are treated in US emergency rooms every day for misuse of prescription opioids. Many more are treated in emergency rooms for the use of such drugs as heroin and fentanyl. The trend is strong in Massachusetts, which ranks at the top among states when measured by opioid-related emergency room visits. Approximately 64,000 Americans, including 1,933 in Massachusetts, died from overdoses in 2016. Hundreds of thousands more were saved by the intervention of clinical professionals. Our health care system is improving at helping people dependent on opioids to survive emergencies, but it is still weak in helping them to recover and live normal lives.
As important as it is to save people’s lives, we will not have a successful policy responding to the opioid crisis until we mitigate the psychological, economic, and societal consequences suffered by living victims of opioid use disorders, their families, and their communities. That requires a highly organized system for quick and comprehensive delivery of the best clinical interventions available. Some people receiving medication-assisted treatment will fail to comply with the recommendations of their physicians, just as some diabetics do when they consume too much sugar or neglect to take their insulin. The correct response is not to punish them by denying medication and thereby subjecting them to the torment of their disease. The best antidote is sustained availability of high-quality care designed to bring each patient as close as possible to normalcy.
Edward M. Murphy was head of three state agencies between 1979 and 1995—the Department of Youth Services, the Department of Mental Health, and the Health and Educational Facilities Authority. He subsequently ran several health care companies in the private sector before retiring.