Moving Opioid Addiction Treatment

If there is any “good news” about the opioid addiction crisis, it is that effective treatment now exists that was not previously available as people are moving opioid addiction treatment into primary medical care. The phrase, “medication-assisted treatment” or “MAT” is commonly used to refer to a range of approaches to treating opioid uses disorders in which medication and psychosocial interventions are used together. Medications such as buprenorphine, methadone, and naltrexone have all been shown to have significant benefits. The psychosocial component ranges from brief counseling to full-scale drug rehabilitation, both outpatient and inpatient.

One size definitely does not fit everyone but research matching individuals with the best treatment for them is still primitive. Furthermore, patients getting access to these treatments is a significant problem. Primary medical care settings are ideal for treating chronic illnesses but are underutilized venues for addressing this particular chronic disease. Addiction treatment specialists are too few and many patients find this path to be unacceptable. The question becomes: how to get primary care medical providers to integrate the treatment of patients with opioid use disorders into their practices?

Different ways to accomplish this were the topic of the Louis Kolodner Memorial Lecture at MedChi for the second year in a row. Last year, Dr. Michael Fingerhood described the model that he has developed at Johns Hopkins Medicine. This year, Dr. Richard Schottenfeld, now the Chief of Psychiatry at Howard University, presented research studies done by Yale University and other centers. These studies demonstrated four successful interventions:

1. Methadone given to already stabilized opioid addiction patients in a primary care setting instead of a specialized opioid treatment program (OTP)
2. Buprenorphine along with medical counseling given in a primary care setting
3. An initial dose of buprenorphine given in a hospital emergency department along with a next-day follow-up appointment for ongoing treatment
4. Injectable naltrexone, although more difficult to initiate for patients than was buprenorphine, was effective for those patients who were able to start it

Two barriers that needed to be reduced to achieve these successes were the disinclination of providers to use these medications and general pessimism about the prognosis of opioid use disorders. My hope is that as more successes are demonstrated, these barriers will slowly be lowered.

For those interested in more details about these studies about moving opioid addiction treatment into primary medical care, I invite you to access the lecture slides, available here: 2018 Kolodner Memorial Lecture- Handout