Philip Seymour Hoffman’s death February 2, apparently from a heroin overdose, catapulted the problem of heroin addiction and overdoses into headlines worldwide. The 46-year-old actor had been in recovery for more than two decades but had slipped back into prescription opioids and then heroin last year, after which he reportedly went to 10 days of “rehab.”
There are 100 overdose deaths a day in the United States. Medication-assisted treatment (MAT) with methadone or buprenorphine could prevent many or all of them. Yet there was very little in news coverage or social media on MAT. In interviews this week, ADAW was told repeatedly that it is stigma — not only the stigma of addiction, but the stigma of methadone in particular — that is contributing to these overdoses.
“Medication-assisted treatment is something we promote here as part of the solution, as a prevention strategy,” said Robert Lubran, director of the Division of Pharmacologic Therapies in the Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration (SAMHSA), and the lead federal regulator of methadone and buprenorphine treatment for addiction. “Why don’t more people talk about MAT? I think it’s still connected to shame and discrimination.”
People who take methadone don’t want other people to know, said Lubran, noting that some patients don’t even tell their spouses. “Can you imagine not telling a loved one you’re taking a medication for diabetes?” Lubran asked. “People just don’t feel comfortable sharing their lived experience with addictions.”
Treatment provider opposition
While medications could destigmatize addiction by making it more “medical,” there is still controversy about these medications. Significantly, much of the opposition comes from within the treatment field itself, with many programs refusing to provide services to patients who are on MAT, and refusing to provide MAT itself.
“For people with opioid dependence, MAT should be the standard of care,” said Michael Botticelli, deputy director of the White House Office of National Drug Control Policy, the single most powerful proponent of MAT in the federal government. “Unfortunately, that’s not the case, and there are far too many people who don’t have access to MAT.”
Botticelli, who as head of substance abuse services in Massachusetts spearheaded an aggressive MAT program there, blames treatment providers themselves. “We have too few treatment programs who have incorporated MAT into their treatment regimen,” he said. “We know MAT has the best retention and treatment rates for people with opioid dependence, and that people who fall out of treatment are at extremely high risk.” Eighty percent of people who leave methadone treatment relapse.
“Part of that stigma associated with MAT comes from within the SUD field,” said Botticelli. “It’s time that we make sure that we are not perpetuating that stigma for families and people affected by opioid addiction issues.”
“All the medical evidence that has accumulated demonstrates that opioid agonist therapy is the most successful form of treatment of opioid addiction,” said Edwin A. Salsitz, M.D., director of office-based opioid therapy in the Department of Medicine at Beth Israel Medical Center in New York City, and an official with the American Society of Addiction Medicine.
Salsitz also blames treatment providers and mutual help groups for the underutilization of methadone and buprenorphine. “These people think that being on MAT is not being in recovery, and that the only true recovery is abstinence from all medications,” he said.
“Another death caused by stigma,” said Walter Ginter, project director of Medication-Assisted Recovery Services (MARS), based in New York City. “How many times are these celebrities going to be sent to rehab before someone realizes that opioid dependence is a disease and not bad behavior?”
Ginter, himself in long-term recovery on methadone, said that “if after a person like Mr. Hoffman isn’t successful being ‘drug-free,’ perhaps one of these ‘celebrity’ advisors would suggest medication-assisted recovery.”
All options should be available to people who have the disease of addiction, said Ginter. “We all understand that there is no such thing as a magic bullet,” he said. But having medication-assisted treatment available might mean “a person like Mr. Hoffman might still be alive if he was pointed in the direction of medication with appropriate supports.”
Lubran pointed out that many communities, and even entire states — he cited Maine in particular, which is currently cutting off Medicaid for 400 people in methadone maintenance (see ADAW, January 27) — are opposed to MAT.
Lubran also cited some judges, included drug court judges, who say they “don’t believe in” MAT, noting that these same judges acknowledge that people who don’t do well in abstinence-based treatment go back to prison. “It seems that some of the court systems out there would rather see someone go back to prison than offer MAT, an option that has a lot of evidence behind it,” he said.
Lubran said that he wasn’t aware of any initiative at SAMHSA aimed at reducing MAT stigma in particular.
Stigma for methadone in particular is also due to the federal regulations, which dictate treatment under strictly regimented rules, said Salsitz. Unlike buprenorphine, which can be obtained in a physician’s office, methadone maintenance can only be obtained in a federally licensed opioid treatment program (OTP). “Up to this point, there’s less stigma surrounding buprenorphine than methadone, because of the regulatory difference,” said Salsitz.
MAT reduces ODs
Botticelli also pointed to a study published in the American Journal of Public Health last year showing that expanding access to methadone and buprenorphine in Baltimore was associated with a reduction in overdose deaths.
“Addiction is a chronic disease, and there is no cure,” said Salsitz. “A relapse can be a minor fleeting event, or it can be death, which is what happened here.”
A relapse can be the end of a marriage, a career, freedom and life — that’s why it’s so important to prevent. MAT prevents relapses, and that’s how it prevents overdoses.
If the patient is getting methadone or buprenorphine at an appropriate dose, there is “minimal or no craving” for an opioid, he said. “The opioid receptors are blocked by the methadone or the buprenorphine,” he said.
Relapse is particularly dangerous because the user is no longer tolerant, and a return to former amounts will have a much stronger, perhaps lethal, effect.
Someone who is in recovery from opioid addiction but having cravings is a candidate for MAT, said Salsitz. “That’s a most reasonable case and a relatively easy case because that person is not dependent at the time,” he said. “That person should certainly be placed on MAT because the relapse is only a matter of time.” Salsitz said he has heard it before: “‘I had a tooth pulled; I knew I shouldn’t take the Percocet but it was painful, and now I’m taking 30 a day.’” The next step is heroin — snorting at first, then injecting, and then, for some, overdose. “That’s the disease of addiction,” Salsitz said.
Many of the people who are on methadone are the people with the most severe psychosocial problems, some of whom aren’t doing well and are using other drugs, said Salsitz. “The people who are doing well are invisible,” he said. “That’s the public relations conundrum, and so far it has been unconquerable.”
Salsitz thinks methadone maintenance needs to be “rebranded,” with an office-based paradigm. “As long as it’s in these clinics, people will be worried about going to it,” he said. At least buprenorphine opened the door to opioid agonist therapy to a population that routinely rejected methadone, he said. Salsitz has been involved in a research project for the past 29 years that does provide office-based methadone maintenance.
But office-based methadone maintenance is not likely to happen, certainly not in the near future, with more and more restrictions placed on opioids.
Why aren’t OTPs and pharmaceutical companies that make methadone and buprenorphine adding their voices to the outcry this week? “I think there is a natural reluctance to venture out and then promote and say, ‘People really do need to come into our particular treatment,’” said Mark Parrino, president of the American Association for the Treatment of Opioid Dependence (AATOD), which advocates for OTPs. “There’s always been the sense of apprehension about being overly promotional, because no matter what, we get whacked,” he said. “People say, ‘Of course you want patients in your facilities, so you can treat them forever.’” And the manufacturers are even more conservative than the OTPs, he said, noting that they are fearful of reprisals from the Drug Enforcement Administration, and also have a pipeline approval process to handle with the Food and Drug Administration. “So they just wait it out,” Parrino said.
Parrino agreed that the Hoffman tragedy is an opportunity to bring MAT to the public eye. “But it’s not so much the message to the public,” he said. “The question is, do you draw out some negative people?”
The death of actor Philip Seymour Hoffman was one of 100 overdose deaths that take place every day, deaths that could be prevented by medication-assisted treatment, officials say.