Saturday, December 7, 2013

Controlling Ohio’s opiate epidemic requires a different treatment approach

Action teams are combating the opiate epidemic, but they are missing the vital piece of promoting medication-assisted treatment

Four Ohioans die every day of opiate overdoses. Yet as daunting as the statistics are, the reality of treating the ravages of our opiate epidemic is even worse. Medication-assisted treatment has become essential.

In 2011, one in 20 Americans used prescription painkillers for nonmedicinal purposes. Hydrocodone, an opiate, is the most frequently prescribed medication in the United States. Between 2000 and 2009, the number of pregnant women who used opiates went up five times.

In the late 1990s, doctors were urged to consider pain as a vital sign. Powerful painkillers were developed and used effectively by competent physicians, but they also were diverted to “pill mills” that sprang up in Ohio and across the nation.

Some greedy or careless physicians prescribed opiates indiscriminately. Other doctors who suddenly realized the problem, or feared government regulation, summarily ended treatment with opiates. That forced many patients who had grown dependent on opiates to get their drugs on the street — or to switch to heroin.

Studies over the past decade have shown that opiate addiction is a chronic relapsing disease, like diabetes, hypertension, and asthma. Relapse rates for people who depend on opiates range from 40 percent to 60 percent — similar to the rates for these other chronic diseases.

Brain scans reveal structural and functional changes in the opiate-addicted brain. Blaming an opiate addict for relapsing is like scolding a diabetic for having high blood sugars.

Addiction crosses all boundaries of race, religion, ethnicity, education, profession, age, and wealth. I’ve seen a 65-year-old suburban professional who is addicted to oxycodone chat with a 25-year-old heroin addict, in a touching display of fraternity.

I have specialized in treating addiction for more than two decades. In that time, I often felt powerless as I recommended abstinence and counseling, only to see relapses and ruined lives.

Medication-assisted treatment changed that. Such drugs as methadone, buprenorphine, naltrexone, and Suboxone can be prescribed along with behavioral treatment, enabling patients to maintain sobriety and regain the ability to function fully.

Methadone is very effective for treating opiate dependence. But because of its potency and high risk of overdose death, it can be dispensed only in maintenance programs that require daily attendance and swallowing of liquid methadone in front of a witness.

Buprenorphine not only binds tightly to opiate receptors in the brain, it also can prevent stronger opioids, such as oxycodone and heroin, from doing so. Higher doses of the drug do not cause euphoria, lowering its potential for abuse.

In medication-assisted treatment, patients get a detailed evaluation, urine drug testing, counseling, assignment to a 12-step program, and a prescription for buprenorphine. Doctors who are not board-certified in addiction medicine can take an online course in buprenorphine and obtain a license to prescribe it.

A pregnant opiate addict should be cared for by an experienced addiction specialist. In that way, the buprenorphine dose is carefully adjusted, the pregnancy is protected, and the intensity of opiate withdrawal in the newborn baby — and the resulting hospital stay — are reduced.

Without treatment, pregnant addicts often use a potpourri of drugs. Such abuse sometimes kills their babies, or causes prolonged stays for newborns in an intensive care unit.

Toledo has its share of addiction specialists. But it also has Suboxone “cash-pay” clinics, where the only activity is the exchange of money for prescriptions. Just as painkiller pill mills created the opiate epidemic, Suboxone pill mills are implicated in overdose deaths.

Action teams convened by Gov. John Kasich and Ohio Attorney General Mike DeWine are doing great work in combating the opiate epidemic. But they are missing the vital piece of promoting medication-assisted treatment.

My family-medicine patients send me thank-you cards, but my opiate-addicted patients write thank-you booklets. One such patient was homeless and hopeless.

He dutifully followed a medication-assisted treatment program for a year. He now has a job, a new car, his own apartment, health insurance, and even a 401(k) retirement plan.

Our collective contempt for the disease of opiate addiction is based on ignorance and misinformation. Criminalizing addiction is inappropriate and ineffective; you can’t punish it out of patients.

Recognizing addiction as a disease, and getting more physicians certified to practice office-based opioid treatment in tandem with counseling and 12-step meetings, can quickly control Ohio’s opiate epidemic.

Mahjabeen Islam, M.D., practices in Perrysburg and specializes in addiction and family medicine.