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12/5/2016 12:00 AM

Extended-release naltrexone (Vivitrol) has been more popular than methadone or buprenorphine in the corrections field. So who better than Kevin Fiscella, M.D., M.P.H., liaison from the American Society of Addiction Medicine to the National Commission on Correctional Health Care (NCCHC), to question the way clinicians decide what medication to use in the treatment of opioid use disorders. In prisons and jails, there has been a bias against the agonists methadone and buprenorphine. The NCCHC last month posted its position statement on the treatment of substance use disorders in correctional facilities, which includes a strong recommendation for treatment with methadone or buprenorphine, and also refers to the use of naltrexone.

Extended-release naltrexone (Vivitrol) has been more popular than methadone or buprenorphine in the corrections field. So who better than Kevin Fiscella, M.D., M.P.H., liaison from the American Society of Addiction Medicine (ASAM) to the National Commission on Correctional Health Care (NCCHC), to question the way clinicians decide what medication to use in the treatment of opioid use disorders (OUDs). In prisons and jails, there has been a bias against the agonists methadone and buprenorphine. The NCCHC last month posted its position statement on the treatment of substance use disorders in correctional facilities, which includes a strong recommendation for treatment with methadone or buprenorphine, and also refers to the use of naltrexone.

In a Letter to the Editor in the November-December issue of the Journal of Addiction Medicine, Fiscella raises the issue of the standard of evidence for naltrexone compared to methadone or buprenorphine. He said that based on the evidence, naltrexone should not be a first-line medication for treatment of OUDs; rather, buprenorphine or methadone should be the first-line medication. In addition, he said naltrexone should only be for highly motivated patients. It’s important to note that much of the evidence about naltrexone refers to the oral form, as extended-release naltrexone — only available as Vivitrol — has little evidence. With oral naltrexone, even if patients are highly motivated, administration should be observed to make sure patients are compliant, Fiscella suggested.

Fiscella’s letter referred to a paper by Alex Harris, Ph.D., and colleagues entitled “Specifying and Pilot Testing Quality Measures for the American Society of Addiction Medicine’s Standards of Care,” published in the May/June issue of the Journal of Addiction Medicine. The paper looked at three measures: pharmacotherapy for alcohol use disorder, pharmacotherapy for opioid use disorder and detoxification. Fiscella’s letter focused on how quality measures should be used in selecting between the three medications approved for the treatment of OUD: methadone, buprenorphine and naltrexone. (Naltrexone is also used for the treatment of alcohol use disorders.)

“Evidence regarding effectiveness and outcomes supports recommendations for methadone and buprenorphine as first-line drugs for OUD under most circumstances,” concluded Fiscella’s letter. “Naltrexone should be reserved for highly motivated, supervised patients. Guidelines and quality measures should reflect this evidence.”

Harris responds

Harris and the co-authors of the original study responded to Fiscella’s letter, agreeing in many areas, in particular on the evidence supporting the effectiveness of methadone and buprenorphine. The difference, however, is that ASAM does not take a position on “first-line” drugs. “The current ASAM guidelines cite the same facts and recommendations, but do not take the step of distinguishing first-line and other medications,” said the Harris letter. However, Harris was welcoming of the dialogue and cited the importance of transparency in developing quality measures.

Harris noted that the ASAM OUD guideline required at least one of the following criteria for recommending a medication: (1) FDA approval for the indication or (2) effectiveness for the indication supported by high-quality meta-analysis. There is “weak meta-analytic support” for naltrexone for OUDs, said Harris in the letter.

“A possible downside of Dr. Fiscella’s proposal is that some patients who are less motivated or not supervised might prefer or benefit from naltrexone, but might not receive it under more prescriptive guidelines and measures,” said Harris. On the other hand, the science supporting methadone and buprenorphine as more effective is there. “A downside to being less prescriptive is that clinicians and patients might not appreciate the underlying science,” said Harris. “We hope in the next revision of the guidelines, discussion will focus on the benefits and potential pitfalls of distinguishing methadone and buprenorphine as first-line drugs for OUD, and carefully specifying the condition under which naltrexone should be considered.”

The Lee study vs. real life

We asked H. Westley Clark, M.D., Dean’s Executive Professor of Public Health at Santa Clara University, to comment on the discussion.

Clark said that both Fiscella and Harris, in assessing evidence, need to consider two key aspects of a paper they both rely on — the paper by Joshua Lee, M.D. (published in the New England Journal of Medicine this spring; see ADAW, April 4) that found that Vivitrol was better than usual treatment — which was no medication — at preventing relapse. Why the Lee paper may not be relevant to the real-world criminal justice system: Lee’s subjects were voluntary participants and not facing criminal sanction for not taking the medication, and — importantly — they stopped taking the medication after the trial was completed, most likely because they couldn’t afford to pay for it.

In the Lee study, the control group (no medication) received the same range of incentives as the Vivitrol group, including encouragement to access other treatment, including buprenorphine or methadone, if preferred, both during the trial and after the treatment phase. Visits were scheduled every two weeks; 79 percent of the Vivitrol group and 75 percent of the treatment as usual group attended these visits.

No participants in the Lee trial continued Vivitrol after the treatment phase. At the time, Vivitrol may not have been accessible to patients relying on public-sector funding, noted Clark.

“In regard to the notion of incentives, the population in the Lee paper did not have the negative incentive of parole, probation or other criminal justice–related remand,” noted Clark. “All the subjects were voluntary. Thus, the idea or notion of incentives, whether positive or negative, is not appropriate for a discussion involving Lee et al.”

So the Lee paper did not address how Vivitrol applies to a real-life criminal justice population, which is faced with consequences of relapse such as reincarceration.

Fiscella concluded that the evidence is lacking that most patients with OUD will continue to show up on their own for monthly injections, without the leverage of the criminal justice system. Clark said this conclusion is “true but fuzzy” because the criminal justice system only concerns itself with the period of supervision, not what happens afterward. “The criminal justice system has leverage in terms of return to incarceration, which is an incentive to return for monthly injections,” said Clark. “The only issue then would be cost and who would pay the cost.”

In addition, one paper cited as evidence that naltrexone has worse outcomes dealt with oral, not extended-release, naltrexone, noted Clark, adding that Fiscella’s conclusion that “higher deaths among those prescribed naltrexone reflected greater nonadherence and relapse” does not seem to be applicable.

Harris and colleagues propose a decision rule that places “effectiveness for the indication supported by high-quality meta-analysis” above FDA approval in rank, noted Clark. But waiting for this meta-analysis is not a good idea during this crisis, he said. “The real-world criminal justice context is unique because it carries with it the threat of sanctions, including loss of freedom,” he said. “Waiting for permission to do the ethical studies in sufficient quantities to generate appropriate meta-analysis could deprive individuals of an alternative to methadone or buprenorphine.” However, if the question of who is paying for the treatment isn’t addressed, the issue of effectiveness can’t be addressed either, said Clark. “What I fear is that the poor under the supervision of the criminal justice system will have a more narrow list of treatment options, given the cost. Or, the poor will be given a Hobson’s choice — pay for extended-release naltrexone or continue in incarceration.”

Next steps for the guideline

“Our hope is that ASAM members and other stakeholders continue to discuss the benefits and risks of these and other alternatives,” said Harris. “Dr. Fiscella has made a reasoned and concise proposal for summarizing current evidence into concrete standards.” However, even assuming that only patients with high motivation and supervised administration should receive oral naltrexone for OUD, there is no data that exists on these concepts, he said. “Thus, we are again stuck with unsatisfying choices, all with attendant risks and benefits,” he said. “We can give credit for giving naltrexone or not, but we have no way of assessing motivation or capacity for supervision.”

The ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use was released last year (see ADAW, June 15, 2015) and published in the May/June 2015 issue of the Journal of Addiction Medicine.

For the new NCCHC position statement on treatment of substance use disorders in correctional facilities, go to http://www.ncchc.org/filebin/Positions/Substance-Use-Disorder-Treatment-2016.pdf. Dr. Fiscella discussed the need to prevent withdrawal deaths in prisons and jails in an interview this summer (see ADAW, July 25).

Bottom Line…

Vivitrol is more popular than methadone or buprenorphine among most corrections officials, but a top corrections medical expert says it should be second-line only.

11/21/2016 12:00 AM

Before the election, the plan for FY 2017 spending was clear: Congress passed a short-term spending bill in September that would keep the government running until Dec. 9, at which point the omnibus spending bill would be released, setting appropriations for the fiscal year that began Oct. 1. Now, President-elect Donald Trump would prefer that he, and not Obama, have a say in appropriations, and wants Congress to go along with him on that. On Nov. 17, Congress decided just that: instead of an omnibus bill on Dec. 9, they will approve a continuing resolution that keeps the government running under current appropriations until March of next year.

Before the election, the plan for FY 2017 spending was clear: Congress passed a short-term spending bill in September that would keep the government running until Dec. 9, at which point the omnibus spending bill would be released, setting appropriations for the fiscal year that began Oct. 1. Now, President-elect Donald Trump would prefer that he, and not Obama, have a say in appropriations, and wants Congress to go along with him on that. On Nov. 17, Congress decided just that: instead of an omnibus bill on Dec. 9, they will approve a continuing resolution (CR) that keeps the government running under current appropriations until March of next year.

There had been indications that Congress had been leaning toward a CR, which has happened frequently. This time, it simply adds to the confusion and concern about what protections will be retained for health care, including substance use disorder (SUD) treatment and prevention.

“The work continues,” said Robert Morrison, executive director of the National Association of State Alcohol and Drug Abuse Directors (NASADAD). He takes an “all-of-the-above” approach when it comes to vehicles for the Comprehensive Addiction and Recovery Act (CARA) or any other funding for treatment and prevention.

ACA, Medicaid

Of greatest concern to the treatment field in general is a threat to the Affordable Care Act (ACA), which both Trump and Republicans in Congress have vowed to repeal. Ron Pollack, executive director of Families USA, issued a call to action after the election. “We must take Trump at his word, and he has repeatedly said his first act would be to repeal the ACA — even calling Congress into special session, if necessary,” said Pollack. “This will have tragic consequences for tens of millions of people, and we at Families USA are going to be on a total war footing to make sure this never comes about.”

Key aspects of the ACA include Medicaid expansion, which not all states participated in, and subsidies for health insurance policies. This was very important for SUD treatment, because in many states, single men were unable to get Medicaid. Also included in the ACA is a list of 10 essential health benefits, one of which is behavioral health care. The ACA also prohibits insurance companies from denying coverage on the basis of pre-existing conditions.

Trump also wants to put Medicaid into a block grant, which would cap it; as an entitlement, Medicaid is not capped at the federal level.

“Studies show that repealing the ACA will force 20 million people into the ranks of the uninsured. Approximately 130 million people with pre-existing conditions will be in danger as insurance companies are once again allowed to discriminate against the sick,” said Pollack. “We will see a return to annual and lifetime insurance caps that can leave people with severe illnesses or accidents in a ‘no-insurance zone’ where they will either go without care or go bankrupt. And women will pay higher premiums again merely because they are women.”

Restructuring Medicaid would jeopardize health care for more than 70 million low-income people, added Pollack. “We will fight at the grassroots level and in the halls of Congress to make sure Mr. Trump’s proposed ACA repeal and Medicaid restructuring don’t happen. Millions of people should not have their lives placed in jeopardy through reckless action.”

Addiction concerns

Becky Vaughn, executive vice president and chief operating officer of the Addiction Policy Forum, said that changing the essential benefit or Medicaid expansion would be a big concern for treatment. “And my biggest worry would be moving Medicaid to a block grant, because with that kind of cap, a lot of people wouldn’t get services,” she said.

A block grant is a fixed amount of money given to a state. Federal Medicaid dollars, by contrast, are only limited by the amount a state spends on Medicaid; the more a state spends of its own dollars, the more the federal “match” is.

On the other hand, Trump did say he favors keeping the pre-existing condition prohibition in the ACA — or whatever the new version of “Obamacare” will be. He also favors the provision allowing families to keep their adult children on their policy until the age of 26.

There is evidence that many more young people have gotten SUD treatment as a result of that provision, said Vaughn. Still, the majority of people who have gotten treatment as a result of public money is either through expanded Medicaid or the Substance Abuse Prevention and Treatment block grant in states that didn’t expand Medicaid, she said.

On the bright side, there is the Mental Health Parity and Addiction Equity Act. This parity law has not yet fulfilled its promise of making treatment for SUDs covered on par with treatment for medical and surgical care, but it’s still in place. “That is of some comfort to us, and we are continuing to push for stronger enforcement of it,” she said.

Vaughn has worked through many administration transitions, having been in the field for more than three decades. But this is different, because of the ACA, she said. “Before, we were mostly thinking about how the new administration would affect the block grant,” she said. “There is a lot more at stake this time.”

Even in a more usual transition, there is a lot of education that takes place, as the former administration passes on information to the new one. However, in this case, precedent will be broken, as the new administration will not be abiding by the budget set by the previous one.

Bottom Line…

Last week, Republicans in Congress put a hard stop to Obama budget priorities, opting for a continuing resolution for the FY 2017 budget instead of the Dec. 9 omnibus that had been planned previously.

11/14/2016 12:00 AM

Donald Trump’s win over Hillary Clinton Nov. 8 was a surprise and, for many, an unpleasant one as they considered the possibility that the gains of the Affordable Care Act (ACA) will be wiped out. Medicaid expansion and the subsidized marketplace insurance plans are likely to be done away with by President-elect Trump and Congress, where both sides have said ACA repeal and replacement are top priorities. Many treatment programs have spent the past five years treating more and more people who now have health insurance. These patients have been treated with medications, in residential treatment programs and in emergency departments, and even the criminal justice system has figured out that it is cost-effective to use Medicaid to provide treatment services.

Donald Trump’s win over Hillary Clinton Nov. 8 was a surprise and, for many, an unpleasant one as they considered the possibility that the gains of the Affordable Care Act (ACA) will be wiped out. Medicaid expansion and the subsidized marketplace insurance plans are likely to be done away with by President-elect Trump and Congress, where both sides have said ACA repeal and replacement are top priorities. Many treatment programs have spent the past five years treating more and more people who now have health insurance. These patients have been treated with medications, in residential treatment programs and in emergency departments, and even the criminal justice system has figured out that it is cost-effective to use Medicaid to provide treatment services.

But ACA repeal isn’t going to happen overnight. Nobody seems to have a clear idea — not in Congress, and so far not Trump — about what to replace it with, and as politicians have realized in states, taking away people’s health insurance is not a popular move.

By now, people have had time to adjust to the new reality. When we interviewed them last week, they were just getting over the shock. For federal employees who were unsure about whether they should retire, this sealed the deal. It’s hard to be inspired to go into public service when the core tenet of the new president has been the negative aspects of government.

The House of Representatives and the Senate are now solidly Republican, so there will be little opposition to Trump’s initiatives.

Other initiatives of Trump and Congress are likely to affect the treatment field and patients. First, criminal justice reform is likely to be halted, as Trump’s “rule of law” philosophy plays out with the support of law enforcement. President Obama’s executive orders will be undone, according to Trump, who specifically cites the one banning federal prisons from being operated by private for-profit companies (Corrections Corporation of America stock went up 45 percent Nov. 9). One of the possible picks for attorney general is Rudolph Giuliani, who as mayor of New York City vowed to abolish methadone clinics there.

Trump has also said he would like Medicaid to be a block grant program, which would put a cap on the amount of money the federal government puts into it.

Marijuana

In other election results, marijuana — medical and recreational — had big wins on Nov. 8. California, Massachusetts and Nevada legalized recreational marijuana (Maine and Arizona were still too close to call), and Florida, Arkansas, Montana and North Dakota approved medical marijuana. In what the Drug Policy Alliance (DPA) termed a “watershed moment,” marijuana prohibition is on the verge of ending — except for Trump, whose administration may threaten marijuana.

“Marijuana reform won big across America on Election Day — indeed it’s safe to say that no other reform was approved by so many citizens on so many ballots this year,” said Ethan Nadelmann, DPA executive director. “But the prospect of Donald Trump as our next president concerns me deeply. His most likely appointees to senior law enforcement positions — Rudy Giuliani and Chris Christie — are no friends of marijuana reform, nor is his vice president.”

Uncertainty

“The theme is uncertainty,” said Robert Morrison, executive director of the National Association of State Alcohol and Drug Abuse Directors. It’s unclear what aspects of the ACA will be kept, if any. But in Congress, the work on opioids is ongoing, with the proposed budget for Fiscal Year 2017 expected Dec. 9, to be finalized before Christmas.

In a Trump administration, “everything is on the table,” said Morrison. “The power of the administration is its ability to set the agenda and put out a recommended path to get there.” So far, despite broad-brush characterizations such as repealing the ACA, there are no specifics, said Morrison.

And opioids, including more money in the FY 2017 budget, are still a top priority for the field. “I don’t see a stop in the intensity of the opioid problem,” said Morrison. “Parents and others affected are still very much for action.”

“A Trump presidency is going to be interesting to say the least, because I’m not sure anyone knows where he stands on many domestic issues, including drug abuse,” Andrew Kessler, principal with Slingshot Solutions, a behavioral health advocacy firm, told ADAW. “This is a man who was fairly centrist earlier in his career, and it’s really anybody’s guess as to whether he will be amenable to positive changes for prevention, treatment and recovery.” Noting that most of Trump’s attention has been focused on drug trafficking in terms of drugs, he did attend an opioid policy roundtable in New Hampshire last month, which, said Kessler, “indicates his willingness to discuss the issue.” Kessler will do what he always does when there is a new administration: “educate him and his team on the complexities of the issue, and get them to include us in discussions that create positive changes moving forward.”

Other voices

“Since January the Addiction Policy Forum has worked diligently to bring addiction and the opioid epidemic to the attention of every presidential candidate, and to review each candidate’s plan to address addiction,” said Jessica Nickel, executive director of the Addiction Policy Forum. “While each candidate’s plan had flaws, almost all showed a significant shift in how to address addiction, reduce current barriers to addiction treatment such as the Medicaid Institutions for Mental Diseases (IMD) exclusion, and the need for additional resources and education,” she told ADAW. “President-elect Trump’s plan included key pieces on prevention, treatment, law enforcement and overdose reversal.” Nickel also cited the New Hampshire roundtable event, at which Trump “focused on prevention and curbing the inflow of illegal drugs into the country.” The Addiction Policy Forum is “committed to working with the new administration to help expand resources to communities at the forefront of the opioid epidemic.”

The National Association of Addiction Treatment Providers (NAATP) “appreciates that President-Elect Trump has expressed his belief that substance use disorder (SUD) is a serious health issue in America,” according to a statement from the Colorado-based group. “We are encouraged that Mr. Trump has publicly discussed the impact of SUD in his own family and has supported treatment for affected employees.” NAATP encourages Trump “to appoint individuals who understand SUD and are committed to the enforcement of the bipartisan Mental Health Parity and Addiction Equity Act as well as the White House Parity Task Force recommendations to fully implement the law.” In addition, SUD is an essential health care benefit under the ACA, which NAATP urges Trump to continue.

“We welcome the opportunity to work with President-Elect Trump and the Republican Party on improving mental health in this country,” said Maria A. Oquendo, M.D., Ph.D., president of the American Psychiatric Association. “Mental health is a bipartisan issue that affects millions of Americans from all walks of life, and we pledge to work with President-Elect Trump’s administration to ensure those Americans get the care they need.”

“As we transition to a new President and Congress, the National Association of Psychiatric Health Systems (NAPHS) and our members are committed to our longstanding, bipartisan advocacy for policies that will improve the lives of the millions of Americans of all ages whose lives are affected by mental illnesses and drug and alcohol use disorders,” said Mark Covall, president and CEO of NAPHS. “The stakes are high for all Americans, with the impact of behavioral health conditions having a wide impact on individuals, families, and communities,” he said. “Alcohol is killing Americans at a rate not seen in at least 35 years, and the United States is experiencing an epidemic of drug overdose deaths.” Lives are at stake, said Covall, adding, “With lives at stake, this is an opportunity for our leaders — both Republicans and Democrats — to come together to take meaningful action on mental health and substance use policies.”

A battle call

And Linda Rosenberg, president and CEO of the National Council for Behavioral Health, provided these words — which are healing and a call to battle at the same time — on her Nov. 10 blog: “I love this quote from Hillel the Elder, one of the most important figures in Jewish history, because I often find myself asking, ‘If not us, who? If not now, when?’ as I think about the National Council’s role in ensuring access to effective care for people with addictions and mental illnesses and in supporting the people in their lives who love them. The outcome of the presidential election doesn’t change the National Council’s answers to the two questions that Hillel the Elder asked. Easily available, effective services is still our true north.” Less than five years ago, most Americans thought of addiction as a “moral failing,” she said. “The response to that failing was incarceration. Acute treatment and belief in a higher power were the primary interventions to what science has taught us are chronic disorders. But over the years together we pushed for change. Because you — the on-the-ground providers of mental health and addiction services in communities across America — believed in a new direction. You applied science to treatment. You created outpatient and rehabilitation programs, incorporating case management, peer and recovery supports, and housing. You worked long and hard to bring behavioral health disorders into health care to integrate the mind and body.”

The outcome of the election “doesn’t change our goal of effective, accessible care and it won’t change or limit the passion and intelligence that our community brings to work with a new administration and Congress,” she said. “But it can mean being prepared to change strategy and tactics and the National Council community is ready to do that.” The meeting will likely be controversial, she said. “Bills may be passed that use the ‘new’ language — reform, value-based, population health — but offer no expansion of service capacity nor invest in quality. We may see proposals that limit entitlements, and that continue to build the gulf between the haves and have nots. We’ve seen it all before and we are prepared to say no loudly and strongly.”

Bottom Line…

President Trump — the field gets used to the reality and what it means for treatment and patients.

In Case You Haven’t Heard
10/10/2016 12:00 AM

The Office of National Drug Control Policy (ONDCP) is asking everybody to change their language when talking about addiction. Actually, they prefer substance use disorder. They also say to stay away from words like “dirty,” “abuse” and “dependence.” All good. After all, even the Diagnostic and Statistical Manual of Mental Disorders no longer uses “abuse” or “dependence” (to describe a pathology), and only the worst kinds of people use the word “dirty” to describe a urine test that is positive for drugs. The ONDCP is even asking for comments on this, in what must be the most frustrating time of the year for substance use disorder treatment advocates who have been trying to pry pennies from Congress for the worst opioid epidemic the country has ever seen. If you want to comment, here’s the draft: https://www.whitehouse.gov/ondcp/changing-the-language-draft. We would like to put in a plug for a change that has been due for some time: “medication-assisted treatment.” What does that even mean? In the field of substance use disorders, we have medications approved for alcohol use disorders (acamprosate, naltrexone) and for opioid use disorders (methadone, buprenorphine, naltrexone). The ONDCP and, increasingly, Congress use “medication-assisted treatment” to mean treatment for opioid use disorders. There’s a huge difference between methadone, which is only dispensed in opioid treatment programs; buprenorphine, which, like methadone, is an agonist (or partial); and naltrexone, which most of the time means the patented extended-release version: Vivitrol. Now “MAT” is in the lexicon — of legislation and regulation — and nobody knows what it means. So can we stop using the phrase “medication-assisted treatment” and just call it medication?

In Case You Haven’t Heard
10/3/2016 12:00 AM

As syringe programs, safe-injecting facilities and harm reduction in general enter the mainstream, what does “harm reduction” even mean anymore? Does it still mean encouraging drug users to get treatment? We asked the policy director of the Harm Reduction Coalition these questions. He is concerned about drug users being left behind as the field gets more mainstream. “Harm reduction has always been grounded in reaching and engaging people who use drugs to support their health needs, including overdose and HIV risk but also substance use itself,” Daniel Raymond told ADAW last week. “So I hope that we’re moving towards building deeper relationships with the treatment and recovery communities so that we can support each other and create a stronger continuum of care.” Raymond also wants to see “more engagement with health care, housing and criminal justice/re-entry,” he said. “Harm reduction philosophy and strategies have a lot to offer and share with these sectors. More broadly, we’re looking at addressing the broader structural issues like stigma, trauma, homelessness and mass incarceration that intersect with substance use and multiply vulnerability and harm.” For more on Raymond’s concerns about mainstreaming the harm reduction agenda, see his piece on the Midwest Harm Reduction Institute’s annual conference, published last week: https://medium.com/@danielraymond/holding-space-for-the-unredeemed-harm-reduction-and-justice-1d70ca675f25#.pbn8uqhcy.

From the Field
9/19/2016 12:00 AM

Opioid addiction is a disorder of brain structure and function. It is an illness. And the most effective treatment for this illness is medication. And as with any illness, the medication that should be used is the one that proves most effective for that patient. And yet, there are those that argue we should limit the medications we use to fight this epidemic of opioid addiction and death.

We’re dying out there. Look at the number of overdoses that have occurred in the last month to heroin and to fentanyl- or carfentanyl-laced heroin. If something, anything, can be used to save lives, then please, let’s put ideology aside and let’s do that. When used as a medication, prescribed by a physician, diacetylmorphine — prescription heroin — stabilizes brain function and allows the person to become well, stay well and, most importantly, stay alive. And this treatment is for those that are refractory to the other medications used to treat this medical condition. Methadone and buprenorphine don’t work for them. So, because those treatments failed, should we just discard the people?

According to the NAOMI study, the countries that have established heroin treatment programs — Switzerland, the Netherlands, the United Kingdom, Germany, Spain, Denmark, Belgium, Canada and Luxembourg — have all reported positive results for those individuals who are refractory to methadone and buprenorphine treatment.

It sounds radical, the provision of heroin to those addicted to heroin. But do understand, a drug is just a drug. It just does what it does. This controversy over using heroin as a treatment to control opioid addiction — it’s not about the data. It’s not about the research. It’s about stigma, ideology and people protecting their turf.

In a previous ADAW issue, Robert Lubran, then with the Substance Abuse and Mental Health Services Administration, stated, “It’s not difficult to find individuals who will prefer access to heroin over methadone maintenance treatment” (see ADAW, Aug. 31, 2009). He seems to believe this is a bad thing. I do not. If we can get more people into treatment, if heroin treatment will do that, how many lives can we save? And every life is someone’s son, it is someone’s daughter, and we would not only be saving them but also their mothers and fathers from the devastating loss of their child. We should be doing everything we can to keep them alive. And, yes, that includes treatment with diacetylmorphine.

The NAOMI studies show that, for those refractory to methadone or buprenorphine, heroin-assisted treatment is effective, with retention rates of about 88 percent. But there seems to be a problem. The acceptance of this form of treatment is opposed by some in the treatment field.

This is not a game. This is not a “my treatment is better than your treatment” contest. This is about saving lives. Heroin can produce addiction, or it can be used to stabilize (with medication) an addiction. It is how we use it that determines its effects. In this epidemic, we have an obligation to do everything we can to save lives. If the use of heroin-assisted treatment will do that, and the data show that it will, then please, put the ideologies aside, put the financial interests aside, push back on the stigma and let’s do everything we can to reduce the harm of this epidemic to those who suffer from this disorder of brain structure and function we call opioid addiction. Because every death, every loss, is someone’s son or daughter, and their lives are precious too.

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  • Meet the Editor

    Alison Knopf
    Editor

    Alison Knopf is a professional journalist who began covering the addiction field in 1984 as founding editor of Substance Abuse Report. She has been the editor of Alcoholism & Drug Abuse Weekly since 2005.
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