Books for Better Living (BBL): Why is the opioid epidemic only getting worse after more than twenty years?
Dr. Adam Bisaga: The most worrisome is the epidemic of overdose deaths related to opioids. This epidemic seems to be escalating due to more powerful opioids appearing on the market in recent years. Initially, only prescription painkillers were available, and these drugs were safer in case of an overdose. There has not been a unified and encompassing response mounted that would include widespread access to the most effective strategy to reduce deaths, which is treatment with medications. There are significant problems in relation to implementing the components necessary for treating addiction successfully such as availability, accessibility, affordability and meeting the specific needs of the individual. More than 400,000 Americans have died from an opioid-related overdose over the past 20 years, despite the fact that effective medical treatments were available.
BBL: Why is opioid addiction so deadly?
Dr. Bisaga: Untreated opioid addiction has high mortality rates because of the high risk of an overdose with each episode of use and the risk of developing serious medical and psychiatric problems, injuries, and social problems. The rate of mortality in opioid addiction is 6 – 7 times higher than in the general population or about 2% per person, per year, with death occurring in many users at a young age. Treatment with medications can reduce this risk by 50 – 70%.
BBL: Why are traditional treatment centers so opposed to using the medical model for opioid use disorders (OUD)?
Dr. Bisaga: The traditional approach to working with individuals addicted to various substances grew out of a mutual-help movement (a 12-step program) to help addicted people find a meaningful life in recovery. This approach, which was developed in the 1930s, before the medical model of addiction was established, is based on a set of spiritual principles and requires abstinence from all “mood-altering” substances. When a variety of medications to reduce substance use became available, traditional programs did not incorporate them. Rather, the two approaches to treating addictions developed in parallel. Some of the medications approved to treat opioid addiction are considered to be “mood-altering,” hence the opposition to their use. Moreover, medical treatment requires a medical professional to coordinate treatment, while traditional programs are mostly nonmedical, and therefore, cannot implement such treatment. While both approaches are useful in treatment of many substance use disorders, only the medical model is acceptable for the treatment of opioid addiction due to the high failure rate of the traditional approach and the high mortality that therapy without medications carries.
BBL: Speaking of treatment drugs that come with a stigma, new research has shown that certain strains of cannabis not only treat opioid addiction withdrawal symptoms (cravings, pain, nausea, etc.), but they have the ability to repair the part of the brain that has been altered by continuous opioid use — that part of the brain that’s responsible for making decisions and good judgment. What are your thoughts on treating opioid addiction with cannabis?
Dr. Bisaga: As far as using cannabis as a treatment for opioid addiction, there is a lot of excitement but little data to support it. Just recently I did an interview with an AP reporter on this very issue because Pennsylvania now has opioid addiction as one of the conditions to be treated with medical marijuana. We know that chronic pain patients who use marijuana take less opioid painkillers. There is also evidence that marijuana or THC (tetrahydrocannabinol) decreases opiate withdrawal. We have observational data showing that patients with opioid addiction who are treated with naltrexone do better. However, patients who use large amounts of marijuana (perhaps having marijuana addiction) tend to do worse in treatment with buprenorphine. The studies about brain repair are from animals treated with CBD, which is a compound of marijuana that has no psychoactive properties. So far, the research is yielding exciting findings, but it is not clear if it will have clinical relevance.
So overall, I believe this research should be pursued, and researchers should be able to do studies with marijuana-derived products, which are still very difficult under the current federal law. However, at this point, it is way too premature to say that cannabis may be helpful in treating opioid addiction. What is useful in treating opiate addiction are FDA approved medications. We know that those are highly effective and should be used as widely as possible and that increasing access to those medications decreases overdose deaths.
BBL: What would you say to family members of people with OUD? What can they do to help their loved one?
Dr. Bisaga: Family members need to seek help from a licensed medical professional, or a treatment program that is equipped to provide treatment that includes medication. A provider does not need to be an addiction specialist as long as they are certified and have some experience prescribing FDA-approved medications. An opioid treatment program, or another addiction treatment program that offers these medications is also an option. Most individuals with opioid addiction do not need residential treatment or detoxification to start treatment with the medication. An important point for patients and families to understand is that in most people, opioid addiction is a chronic disorder of the brain, and the changes made to the brain as a result of opioid use, are responsible for the symptoms that remain for many years — even in people who are able to live in abstinence from all drugs. Therefore, treatment duration has to match the chronic nature of the brain disorder. The best outcomes are achieved by patients who remain in treatment with medication for at least 1 – 2 years — longer is even better. This is a standard approach used in the treatment of other chronic disorders such as diabetes or hypertension.
BBL: Is there hope? What needs to happen for the epidemic to start turning around?
Dr. Bisaga: A lot of changes will need to take place to slow down the accelerating rates of overdose deaths and start bringing dose deaths down. An important place to start is to focus on the immense treatment gap. Only 10 – 20% of patients with opioid addiction receive medical treatment, in contrast to most other chronic medical disorders. There is an example of a response to the HIV/AIDS epidemic in the 1990s, a chronic disorder that at its peak had a comparable number of deaths as the opioid epidemic. Only two years after the medications to treat HIV became available, the number of deaths went down from 50 to 20 thousand a year owing to the massive public health response that included training of providers, subsidies to treatment, grassroots mobilizing to assure that treatment was free, campaigns against stigma and misinformation, and the creation of the separate office of research within the NIH to accelerate development of new treatment. While opioid addiction is a different disorder than AIDS, it requires the same kind of dynamic to effect change.
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