In what he has probably come to see as a big mistake, Health and Human Services (HHS) Secretary Tom Price, M.D., went to West Virginia two weeks ago and disparaged methadone and buprenorphine treatment for opioid use disorders, telling the Charleston Gazette-Mail, “If we’re just substituting one opioid for another, we’re not moving the dial much” (see ADAW, May 15).

“His statement is deplorable,” Charles O’Brien, M.D., Kenneth E. Appel Professor of Psychiatry and vice chair of psychiatry at the Perelman School of Medicine at the University of Pennsylvania, told ADAW last week. “I would be happy to tutor him on the science of addiction. He is obviously not aware of the science. Is there any addiction scientist in Atlanta who knows him? He is an orthopedic surgeon so he should be able to understand science.”

The sad fact is that Price’s language is similar to the language of many educated people — including physicians — who do not understand the science of addiction. “Trading one addiction for another” is the shibboleth haunting the treatments with evidence of success for opioid use disorders — methadone and buprenorphine.

Still, his statement more closely mirrors the philosophy of a rural legislator than anything seen from the federal government. The Substance Abuse and Mental Health Services Administration, the Food and Drug Administration, the National Institute on Drug Abuse, the Office of National Drug Control Policy (ONDCP) and Elinore McCance-Katz, M.D., Ph.D., President Trump’s nominee for assistant secretary for mental health and substance use at HHS, all support methadone and buprenorphine treatment, as well as naltrexone, as approved medications to treat opioid use disorders.

Mark Parrino, president of the American Association for the Treatment of Opioid Dependence (AATOD), is also hoping McCance-Katz will provide valuable input when she is confirmed. “In my judgment, the secretary may not have a full understanding of the value of medication-assisted treatment for opioid use disorders,” Parrino told ADAW. “I am confident that Elinore will be able to provide all of the necessary material to the secretary in support of this work once she receives Senate confirmation.”

Price likes Vivitrol

Alleigh Marre, national spokeswoman for HHS, tried to put out the fire by sending reporters a transcript of the Gazette-Mail interview. In that transcript, however, Price goes straight from damning methadone and buprenorphine to praising Vivitrol:

“I think what I know about health care is that what’s right for one person isn’t necessarily right for another person, but I do know that if we just simply substitute buprenorphine or methadone or some other opioid-type medication for the opioid addiction, then we haven’t moved the dial much. And so what we can do to try and find the medications that aren’t the agonist, the antagonists. Vivitrol is an example. It’s a medication that actually blocks the addictive behavior as well as the seeking behavior. That’s exciting stuff. So we ought to be looking at those types of things to actually get folks cured so that they can come back and become productive members of society and realize their dreams.”

There are only three medications approved for the treatment of opioid use disorders: methadone, buprenorphine and naltrexone. Vivitrol is the patented form of extended-release naltrexone — a once-a-month, $1,200 injection that blocks the effects of opioids, and requires at least a week of opioid abstinence before it can be administered. Vivitrol is an antagonist; methadone and buprenorphine are both agonists, and are opioids. The federal government has never picked one of the medications over another — until Price made his comments in West Virginia.

Outrage

Outrage from medical societies, physicians, treatment professionals and researchers ensued. On May 15, National Public Radio released a letter signed by more than 700 researchers calling Price’s language “unscientific” and “damaging” (see http://www.npr.org/sections/health-shots/2017/05/16/528614422/prices-remarks-on-opioid-treatment-were-unscientific-and-damaging-experts-say).

Ousted Surgeon General Vivek Murthy, M.D., took on Price with a response on Twitter (https://twitter.com/vivek_murthy/status/862776718632857601).

The American Society of Addiction Medicine (ASAM) was preparing its own sign-on letter. In the meantime, ASAM President Kelly J. Clark, M.D., told ADAW that “ASAM was discouraged to hear of Secretary Price’s initial comments regarding medications to treat opioid addiction.” She added: “The evidence is clear that all FDA-approved medications can help patients enter and sustain recovery when offered as part of an individualized treatment plan. As a physician, Dr. Price is well-versed in evaluating the evidence and implementing corresponding policies. We hope the addition of a second physician with specific addiction expertise in the assistant secretary role will magnify the attention the administration can bring to evidence-based approaches.”

Clark said ASAM looks forward to working with Price and the entire administration “to improve access to evidence-based addiction treatment and reverse the course of the opioid epidemic.”

All three medications

“The Office of National Drug Control Policy, which drafts and oversees implementation of the president’s drug control strategy, promotes evidence-based approaches to addressing drug use and its consequences,” said Mario A. Moreno Zepeda, spokesman for the ONDCP. “Among other things, that includes expanding access to medication-assisted treatment [MAT], not only in traditional health care settings, but also the criminal justice system.” He added, “When I say ONDCP supports expanding access to MAT, that includes all three FDA-approved medications.”

Becky Vaughn, vice president of the Addiction Policy Forum, said there are “powerful, evidence-based tools in our treatment toolbox for those with opioid addiction,” she told ADAW. Vaughn was at a meeting sponsored by TCA on May 17 where Sarah Arbes, principal deputy assistant secretary for legislative affairs of HHS, was on the panel. Vaughn requested that Arbes get the message to Price that “we need his public support as well as financial resources to ensure that everyone has access to these medications when they are appropriate,” said Vaughn. Arbes “replied that he is in full support of all modalities of treatment, including medication-assisted therapies.” Vaughn spoke to Arbes afterward and was told HHS is “trying to tamp this down.”

The National Association of Addiction Treatment Providers (NAATP), whose members are mainly residential rehabilitation treatment programs, had a slightly different take on the debate. “For myself, I don’t view the secretary’s comments as alarming,” NAATP Executive Director Marvin Ventrell told ADAW. “The intention of HHS is not entirely clear to me,” he said. “But if what he has said is that MAT alone, without other evidence-based integrated components of care, is insufficient, I wouldn’t disagree,” he said. “We wouldn’t want HHS to discount the value of MAT, but we also want them to embrace time-honored psychosocial treatments.”

In making these incendiary remarks — possibly quite innocently — Price may have done everyone a favor by finally bringing the agonist-antagonist debate into the sunlight. Medication-assisted treatment has come to mean all three medications. But since different camps favor one or the other and use the phrase to mean different things, maybe it’s time to stop using it. Law enforcement, corrections and drug courts favor Vivitrol. But the choice is one that should be made by the patient. So let’s take the first part of Price’s response — “I think what I know about health care is that what’s right for one person isn’t necessarily right for another person” — and move on from there.

Bottom Line…

HHS Secretary Tom Price outraged addiction treatment experts by calling methadone and buprenorphine “just substituting one opioid for another.”