It's important to stress the difference between dependence and addiction.  Dependence is the tolerance one develops over time and the withdrawal one suffers after stopping a drug.  Addiction is a behavioral disorder that refers to the desire a person feels for the effects of a drug and the loss of control over their lives that they have in order to obtain it.

Today we'll be looking at the treatment options available for those who are addicted or dependent on opioids.  This is Healthcare Triage.

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This episode is brought to you in part with generous support from the National Institute of Healthcare Management.  

A drug addict unfortunately spends much of their day either high or sick.  The goal of pharmacotherapy to help with addiction is to reduce the amount of time spent feeling sick without achieving the high.  Unfortunately, we don't use this kind of therapy as often as we should.  Part of that is economic.  We expect insurers and public health groups to fund it, but the savings are realized by society at large.  Asking insurers to pay for a program when the goals are a reduction in prison sentences doesn't always make sense to the insurers.

Another reason is the therapy isn't well understood.  Some people think that using drugs like methadone or (?~1:07) is just swapping out one addiction for another.  The media hasn't always helped with this perception.  The best way to treat addiction is to prevent it.  We all knew that too many prescriptions for opioid painkillers were being written.  Policies were put in place to try and reduce the number of unnecessary prescriptions.  

In 2012, Blue Cross Blue Shield of Massachussets started to require prior authorization for more than a one month supply of opioids in a two month period.  In just a year and a half, this cut the number of prescriptions by more than six and a half million pills.  

Another issue is that many still feel like drug addiction is a moral failing rather than a personal and public health issue.  Usually treatment begins with detoxification, where we try to beat the cycle of withdrawal.  It often continues with rehab, either in the inpatient or outpatient setting, often with pharmacotherapy as well as behavioral therapy.  Unfortunately, therapy often doesn't stick.  About half of those in rehab relapse.

Behavioral treatments work to help patients learn to live without drugs, to overcome cravings, to avoid situations that can make drug use more likely, and to deal with relapses.  The objective of treatment is to reduce dependence on drugs, to reduce morbidity and mortality caused by them, to improve mental and physical health, to prevent illicit behavior, and to help people re-enter society.  

Nalatrexone is an antagonist medication, which means that it blocks opioid receptors.  When someone is given naltrexone, then the opioids don't really work.  It can treat both overdoses and addiction, although it's not as widely used for addiction as people don't take it consistently or tolerate it well.  If you stop taking it, you can also get high soon after.

Methadone is a synthetic opioid agonist, meaning that it works much like opioids do.  It acts in the same receptors in the brains that the other opioids do and in doing so, relieves withdrawal symptoms and reduces cravings for the drugs.  Methadone is one of the most popular forms of treatment for addiction.  It's been shown in research to reduce hospitalizations and emergency department visits, but those are only the direct costs.  If you also include societal costs like low productivity and crime, it's hard to argue that methadone therapy for opioid dependence isn't cost-saving.

It's a full (?~3:16) opioid receptor agonist.  It has a slow onset of action and a long elimination half-life, something like 24-36 hours.  A longer acting derivative known as (?~3:26) exists as well.  It is only taken three times a week.  However, concerns about cardiac effects has made it less widely used than other drugs.

Buprenorphine is a partial opioid agonist, meaning that it works a bit like an agonist and an antagonist.  It also reduces cravings and decreases symptoms of withdrawal.  A number of randomized controlled trials have shown it to be significantly better than placebo.  It's not clear, however, if it's superior to methadone.  Buprenorphine is sometimes unfairly characterized, like many of these drugs, as synthetic heroin, but the drug is materially different than illicit opioids.  

One formulation, (?~4:04), differs from other buprenorphine regimens in that it combines naloxone in the formulation, making a euphoric experience from either the buprenorphine or any other opioid pretty much impossible.  

All of these pharmacotherapy treatments have some problems, though.  Demand for treatment programs is very high and many of them have waiting lists.  Access to these programs can be especially difficult in rural areas.  Even after you get in, they're also very expensive.  Insurers don't always pay for drug treatment programs and many pharmacotherapy programs don't accept insurance even when it's willing to pay.  Paying for office visits and medication can be a significant financial burden for those in recovery.  

It's important to remember that addiction leads to real changes in the brain.  Withdrawal leads to real symptoms, including diarrhea, abdominal pain, nausea, vomiting, aches, pain, and changes in mood.  Those are just words, though.  The agony of withdrawal is very, very unpleasant and people will do almost anything to avoid it.  

Finishing detox relieves the physical effects of addiction and withdrawal, but it's the social factors and psychological effects that lead people to relapse.  Long term maintenance therapy can help.  Narcotics Anonymous is a 12 step program with a process to help people overcome addiction.  It's abstinence based, which means that it's opposed to the use of drugs and maintenance therapy.  This can, of course, be controversial.  Some counseling programs are more compatible with maintenance therapy.  These can include cognitive behavioral therapies like the SMART Therapy program, motivational interviewing, and family therapy.  

Opioid abuse has become such a big problem that treatment is very, very important.  Given the significant relapse rates, though, we need to continue to look for new and better ways to treat addiction.  Overcoming the stigmas attached to treatment is a good start.  Understanding addiction as a change in brain structure rather than a moral failing is essential.  We also need further research in improvements in maintenance therapies and improved access to the treatments we have.

We know we spent a lot of episodes on opioids recently, but they're a real problem for too many Americans.  These powerful drugs have been in use by humans for a long time and they're likely to remain a fixture on the human landscape into the foreseeable future, for better and for worse.  Hopefully a better understanding of how these drugs work, how they can help people, and how they can be dangerous, will help us to get to a place where they can be used safely and for a short period of time.

Healthcare Triage is supported in part by viewers like you through patreon.com, a service that allows you to support the show through a monthly donation.  We'd especially like to thank our research associates Joe Sevits and M.T. and our surgeon admiral Sam.  Thanks, Joe, M.T., and Sam!  More information can be found at patreon.com/healthcaretriage.