Areas of Consensus on Opioid Treatment

After reading the essays and responses in this Cato Unbound issue, the differences of opinion seem to center mainly on the origins and cause of increasing rates of opioid involved morbidity and mortality seen in the United States in the last several years. This is an issue where debate will continue, particularly in light of the recent decision in Oklahoma against Johnson and Johnson, and the Ohio case against the pharmaceutical industry set for October.

Regardless of these differences, I believe we have consensus in the following areas. Stigma has resulted in policies detrimental to the long-term health and well-being of people with substance use disorder, and both harm reduction programs and access to medications to treat opioid use disorder should be expanded.

There are a multitude of programs included under the category of harm reduction, from overdose prevention sites (also called safe consumption facilities) to syringe services programs, to naloxone distribution. Syringe services programs are gaining more acceptance nationally, with states such as Florida legalizing syringe exchanges earlier this year. In Kentucky, identified by the Centers for Disease Control and Prevention as having several counties at elevated risk for outbreaks of blood borne diseases due to injection drug use, syringe services programs have become a central element of the state’s opioid response. Kentucky passed legislation in 2015 legalizing syringe services programs, and as of February 2019, 47 counties in Kentucky have programs.

A final area of consensus in these exchanges is support for increased access to medications for the treatment of opioid use disorder. One of the essays, by Dr. Jeffrey A. Singer, discussed removing the federal waiver requirement necessary to prescribe buprenorphine; equal emphasis should be applied to removing the significant barriers to methadone treatment. Methadone can only be dispensed in a specially licensed facility that is subject to a multitude of federal and additional state requirements. Calls for revising federal law and allowing the mainstreaming of methadone treatment into health care have not resulted in congressional action.[i] Reforming the entire system of methadone treatment for opioid use disorder may be years away. However, an important first step could be taken to expand methadone availability by lifting the ban on new methadone vans, a moratorium that has been in place since 2007.

The Drug Enforcement Administration (DEA) licenses methadone vans and a new rule must be issued by DEA to lift the moratorium. Methadone vans are often used in underserved or remote areas where opioid treatment facilities are unavailable. Lifting the moratorium and allowing new methadone vans will provide areas of the country in dire need of additional treatment access to this effective medication. A wholesale rethinking of laws around methadone treatment may be necessary, but in the meantime, this is an essential and urgent first step.

Note

[i] Samet, J.H., Botticelli, M., & Bharel, M. (2018). Methadone in Primary Care - One Small Step for Congress, One Giant Leap for Addiction Treatment.The New England journal of medicine, 379 1, 7-8 .

Also from this issue

Lead Essay

  • Pain, Opioids, and Addiction: Searching for a Nuanced Solution by Travis N. Rieder

    American pain medicine is desperately broken, says bioethicist Travis N. Rieder. To fix it, we must avoid swinging the pendulum too far toward over-medication—and too far toward under-medication. Either of these mistakes can drive patients toward the dangerous illicit opioid market. Instead, Rieder recommends harm reduction strategies, including safe injection sites and even prescriptions for pharmaceutical grade opioids to minimize the harms of addiction.

Response Essays

  • Prescribers and Policymakers Must Both Get Better at Harm Reduction by Jeffrey A. Singer

    Jeffrey A. Singer agrees that pain is individualized and thus difficult to assess. The War on Drugs has made practicing medical pain management much more difficult, because doctors have grown averse to prescribing opioids, particularly in high doses. But it was not doctors prescribing too freely that prompted the recent crisis, and when doctors withdrew these medications, many patients turned to the streets.

  • Fight the Opioid Epidemic with Stigma-Free Treatment by Gail D’Onofrio

    Gail D’Onofrio says that clinicians have a good idea of what works in fighting opioid addiction and dependency. She calls for a multifaceted approach that involves medication, more treatment professionals, and ending the stigma of seeking treatment, which can often drive away people who would otherwise seek help. She outlines a variety of legislative and clinical practice reforms that she believes will help prevent and treat substance use disorders in the future.

  • Criminalizing Addiction Isn’t Working. Prevention and Treatment Deserve a Chance. by Regina LaBelle

    “The chronic and relapsing nature of addiction—the very symptoms of addiction—are punished and criminalized,” writes Regina LaBelle, who argues that this punishment is counterproductive. The criminal justice system has become the default primary care provider for many and perhaps most addicts, and this situation helps no one in society, not even those who never use drugs at all.

The Conversation