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Addiction experts have new tools, tough challenges

From the Pittsburgh Post-Gazette.

by Rich Lord

SAN DIEGO — After years of surging overdoses, some of the officials and medical practitioners most deeply involved in the fight against opioids have hope that they finally have the tools, the funding and the public support needed to get the epidemic under control.

“I have some cautious optimism,” Debbie Dowell, a senior medical adviser at the federal Centers for Disease Control and Prevention, said at the annual conference of the American Society of Addiction Medicine, which ended Sunday in San Diego.

Even as fentanyl and carfentanil have killed more and more people in some states, a few other states have begun to reverse the trend, she said.

The epidemic is an opportunity to “change the way addiction medicine is treated across the board,” by integrating it with the broader medical community, Wilson Compton, deputy director of the National Institute on Drug Abuse, said at the conference attended by 2,100 professionals. “It truly is a remarkable time right now.”

The federal government last month dedicated a record $4.6 billion to fighting the opioid epidemic. The key tool most often cited is the drug buprenorphine, most often known by the brand name Suboxone, which is becoming available in new forms, including some that quench the craving for opioids for months. Buprenorphine, an opioid, is often combined with naltrexone, which prevents other opioids from binding to the brain’s receptors.

Treating one opioid with another has been controversial ever since the introduction of methadone for that purpose in the 1950s. Many advocates of complete drug abstinence, in the recovery community and the criminal justice system, view methadone and buprenorphine with skepticism.

This year, though, the federal government has declared that methadone, buprenorphine and naltrexone — often known by the brand name Vivitrol — are the “standard of care,” or “gold standard,” for treating opioid addiction.

“Medication assisted treatment … to treat opioid use disorder, is an evidence-based practice that people need to have access to,” Elinore F. McCance-Katz, first assistant secretary for mental health and substance use with the U.S. Department of Health and Human Services, said at the conference.

Officials and addiction doctors think they have the power to loosen the chokehold of opioids — if only they can get to more of the millions of Americans addicted to prescription opioids, heroin and fentanyl.

“We know that this is a very treatable illness,” said Laura Kehoe, a Boston psychiatrist and assistant professor at Harvard Medical School. “The pressure is on us to find a way to get people engaged and to stay in care.”

Baltimore has been there

Few, if any, American cities have more heroin-fighting experience than Baltimore. Some 15 years ago, overdoses climbed, but the city “achieved a really dramatic reduction in heroin-related overdose deaths with expansion of buprenorphine and methadone,” said Yngvild Olsen, medical director for the Institutes for Behavior Resources, a drug treatment center in Baltimore.

“And fentanyl now is really the thing that has driven [overdoses] back up again,” she said.

So the city is doubling down on buprenorphine, a drug introduced in 2003.

Starting a year ago, when someone shows up at a Baltimore hospital with an opioid overdose or similar emergency, they typically get a dose of buprenorphine, introduction to a “peer recovery coach” employed by the hospital, and an appointment the next day at one of some 25 “fast track” treatment sites.

The coach — typically a recovering drug user — tries to make sure the patient reports to the site and starts longer-term buprenorphine treatment. Of the first 400 patients for which the strategy was used, around 40 percent started the “fast track” buprenorphine treatment, Dr. Olsen said.

Traditionally, drug rehabilitation has been isolated from the rest of medicine, and detox, methadone, buprenorphine and naltrexone have been handled by different doctors, said Marc Fishman, medical director of Maryland Treatment Centers in Baltimore. He’s working on what he called “a soup-to-nuts inpatient-to-outpatient campus, where we’re going to have all three” drugs, plus other therapies.

“With money coming from the federal government, and political will both on the state and the city level, and strategic plans that really are going to include some innovative efforts going forward, I’m optimistic,” Dr. Olsen said.

The death rate, she said, will go down. “It’s going to take us a while to get there, but we’ve seen it before.”

Rhode Island reduced overall overdoses by increasing the use of the medications in prisons and steering released inmates to treatment facilities, the CDC’s Dr. Dowell said. The state cut in half the fatal overdose rate among recently released prisoners.

The smallest state has also become forgiving of relapses, said Dr. McCance-Katz, who hails from there.

“Now people, if they relapse, they can come back” to treatment, she said. “So they can come back, they can get restabilized, and then they go back to communities. I believe that is going to be one of the ways that we get this issue under control.”

Problems, persistent barriers

“I feel optimistic because of the amount of money, attention and programming that’s happening,” said Stuart Fisk, director of Allegheny Health Network’s Center for Inclusion Health, adding that the medical community is slowly moving away from the “moralistic, abstinence-only approach to drug treatment.

“But I think we’ve got a long road ahead of us.”

Mr. Fisk attended the conference along with Mitch West, AHN’s medical director of addiction services.

“I’m not yet what you would call optimistic,” Dr. West said.

He has more tools, steadily more buy-in from other doctors at AHN and improving relationships with skilled nursing facilities. On the other hand, he’s seeing patients with both drug problems and the many medical complications associated with dirty needles.

“There is such widespread injection drug use with these ultra-potent agents,” he said. “I didn’t see spinal epidural abscesses in 20 years in the ER, and now we see one a week in the ER.”

He’s seeing patients in their 20s who need heart valve replacement, bone surgery and even, in one recent case, brain surgery because of infections caused by injecting. Given that, it’s hard to be cheery.

“We don’t have expansion of syringe access or of syringe programs in Pennsylvania,” Mr. Fisk said. “That is one thing the governor has not moved on and that we are not in the forefront of in this country.”

Allegheny County so far has finalized 728 autopsies for fatal drug overdoses for 2017, of which around three-quarters involved fentanyl.

Overdoses are just the worst cases.

Some 11.5 million Americans misuse prescription opioids, including some 2 million that have “opioid use disorder,” or addiction, Dr. McCance-Katz said. She said that in 2016 another 948,000 used heroin, up from an estimated 828,000 in 2015 and just 404,000 in 2002.

Of the millions of Americans with opioid addictions, an estimated 20 percent are getting treatment, she said. Of those getting treatment, only 37 percent are getting the three proven medicines — methadone, buprenorphine or naltrexone — she added.

“Why aren’t people using it?” asked Kelly Clark, president of the American Society of Addiction Medicine. “What are the reasons? And if we had a little more clarity on why they’re not being used, it may be easier to address some of the barriers more specifically.”

One barrier: The medications aren’t perfect.

Methadone can be abused, leading to fatal overdoses, and is extremely hard to quit. Most forms of buprenorphine aren’t very dangerous by themselves, but can be deadly in combination with other drugs, including benzodiazepines like Xanax. When naltrexone wears off, cravings for opioids can return rapidly, leading to relapse and overdose.

The drugs are being improved, so that a single shot will last a long time, Dr. McCance-Katz said.

“I’m a big fan of the long-acting preparations that are injectable,” because such drugs can’t be diverted to the black market, she said. “And I think that it takes away that decision that people have to make every single day when they’re trying to recover as to whether to continue their medications.”

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