The National Academies’ Report is grounded and is well referenced. It is published at a time when the nation continues to grapple with unceasing opioid related deaths and a changing epidemic.
The strength of the Report is its view that Medication-Assisted Treatment for Opioid Use Disorder should be considered a first line method of confronting the epidemic.
There are other parts of the Report that question the efficacy of using behavioral therapies in conjunction with such medications.
Medication-Assisted Treatment should be a first line opportunity to treat Opioid Use Disorder. One of the most significant aspects of the Report is moving away from the term Medication-Assisted Treatment and describing current practices as being Medication-Based Treatment. The shift in language is significant. More than 15 years ago, SAMHSA and other agencies coined the term Medication-Assisted Treatment, indicating that when medications were used to treat Opioid Use Disorder, clinical support services should be used in conjunction with the medication.
The Report makes a very good point in explaining one of the knowledge gaps in how we have provided access to federally approved medications to treat this disorder.
Because each medication has a distinct mechanism of action, the most appropriate medication and dosage varies across patients and may vary in the same patient over the course of treatment. The existing medications are very effective, but they are not perfect; for example, evidence gaps remain about how to choose the most effective medication for a particular patient and how best to retain people in treatment, which is itself a significant problem. Moreover, because OUD has complex behavioral and social causes and consequences, it is not yet known which behavioral interventions might be most appropriate to help restore patients to full functionality.
Herein lies the rub. The Report clearly reflects an understanding of the complex nature of the disease in that OUD is simply not a neurological disorder. Like most complex illnesses, it has a number of behavioral components. One might argue this represents a contradiction in the approach of medication being the treatment.
There is a seventh conclusion, which is an integral part of the Report’s approach in dealing with this public health crisis. “Current regulations around methadone and buprenorphine, such as waiver policies, patient limits, restrictions on settings where medications are available, and other policies that are not supported by evidence or employed for other medical disorders.”
There have also been a number of policy approaches, which argue for the elimination of the SAMHSA/DEA regulations governing OTPs as a method of expanding access to the treatment system. The argument in this case is that the existence of these regulations restricts access to care. This is not the case. The true limitation to access to the availability of OTPs are based on zoning board restrictions, legislative interventions, moratoriums on opening new OTPs and the lack of third-party reimbursement.
The second chapter in this Report discusses how medications are used. There are descriptions about the major medications used to treat this disorder. There is an interesting issue in the section that discusses buprenorphine,
Because it is a partial agonist, buprenorphine also has less of an effect on respiratory depression, so it has a lower risk of overdose than methadone and other opioids (Dahan et al., 2006), and a therapeutic dose may be achieved within a few days (Connery, 2015).
What is interesting about this section is that it never describes the dosage ceiling effect of buprenorphine. Buprenorphine is an effective medication and people by the thousands have gotten access to such care through DATA 2000 practices. The point here is that in such a scientific paper with so much evidence and so many references, the dosage ceiling limitation of burprenprohine is never discussed.
There is a brief but important section in the second chapter, which talks about patient preferences.
Patients’ preferences about medications to treat OUD are fundamental in determining whether they start and stay on treatment for OUD, but those preferences have yet to be fully explored. Some informative data about patients’ medication preferences are available from Rhode Island’s correctional system and the state of Vermont. In both populations, methadone is the most common choice among people receiving medication for OUD (between 60 and 70 percent), with buprenorphine preferred by the remainder of patients.
What is not stated in this chapter but is also important, is the difference in how patients get access to certain medications in different environments, not based on patient preference but based on the preference of policymakers, who have no idea about how to clinically treat Opioid Use Disorder. The issue of patient preference, as stated in the Report, is paramount in leading to treatment retention and effective care in the long term.
The bottom-line is that the National Academies Report is thoughtful and comprehensive. It provides an important inflection point in how we treat Opioid Use Disorder in the United States.
The deregulation of the treatment system depends on where you happen to sit. From a public health, harm reduction point of view, which does not necessarily take into account the issues of treating this disorder through clinical methodologies, the issue of removing all barriers makes sense. With regard to how the treatment system actually functions in reality and how patients are treated, with what medications and under what circumstances and what treatment environment, is a completely different matter.