Medication Assisted Treatment for Opiate Addiction

Medication Assisted Treatment for Opiate Addiction.

We were chatting with a long-time friend, a well-respected psychologist who consults with a drug court, about medication assisted treatment for opiate addiction, specifically the use of buprenorphine to assist individuals with their drug addiction.  We were surprised to learn that the drug court he works with is opposed to the use of opiate replacement medication.  The drug court’s reasoning is based on the belief that reliance on any medication is not true recovery from addiction. In contrast to the drug court’s belief, we had just read a long article in the Huffington Post that makes the point very persuasively that buprenorphine saves lives of individuals addicted to opiates. We started poking around to learn more about these divergent points of view, and learned some interesting things about the issues of buprenorphine and other opiate replacement drugs.

NIDA Research Created Buprenorphine

Buprenorphine is the result of research sponsored by the National Institute on Drug Abuse (NIDA) to find a replacement drug for heroin.  The FDA approved it in 2002 for opiate replacement treatment.  However, buprenorphine has some additional off-label benefits that we’ll discuss in a few paragraphs.

There’s a Term for it: Medication-Assisted Treatment

Medication assisted treatment for opiate addiction includes the use of certain drugs (buprenorphine, methadone, and naloxone) that are used in conjunction with counseling to treat addiction.  Buprenorphine and methadone satisfy the body’s craving for opiates, the idea being that the addicted person will not feel the physical need to take opiates.  The replacement opiates satisfy the body’s physical craving without inducing the intense euphoric high that opiates produce.

Must Medication be Conditional Upon Receiving Counseling?

Maia Szalavitz, in an article for The Influence makes a persuasive case that buprenorphine and methadone save lives even without being used in conjunction with counseling.  An individual with methadone or buprenorphine in their system has a higher tolerance for opiates, and thus is less at risk from dying from an accidental overdose of opiates.  Studies have shown that it is the replacement opiate, rather than the counseling, that makes the biggest difference in recovery from addiction.

Yet typically, substance abuse treatment protocols require an individual to participate in counseling in order to receive buprenorphine.  Ms. Szalavits makes the case that offering the opiate replacement drugs, regardless of the whether the individual participates in counseling, reduces harm to the individual and has substantial benefit.  The analogy is prescribing insulin for a diabetic:  would a physician withhold insulin from a diabetic individual if the individual refused to exercise and modify their diet?

The Absurd Limitations for Prescribing Buprenorphine

Here’s a riddle:  Why are there no limits on the number of patients a doctor may prescribe oxycodone, a Class II drug, but there are limits on how many patients a doctor may write prescriptions for buprenorphine, a Class III drug?  (Class II drugs are more addicting than Class III drugs.)  Not only are there restrictions on the number of patients for buprenorphine, doctors must take special training to get a waiver from DEA to write the prescriptions.  It’s just a thought, but we wonder what would happen if the DEA switched things around and limited the number of prescriptions doctors could write for oxycodone and other synthetic opiates?

Off-Label Use of Buprenorphine

In another interesting article from The Influence a family physician writes about the benefits of using buprenorphine with individuals who become addicted to opiates used to manage pain.  These individuals don’t fit the classic definition of “drug addict.” They can still function adequately in their families and in society, but they have psychological and physical cravings for the drug, and may also have increased pain as a paradoxical effect of opiate addiction.  (One of the effects of opiate addiction, called opioid-induced hyperalgesia, makes the individual even more sensitive to their pain, and so individuals must take increasingly larger doses of the opiates to deal with the pain.)  Replacing opiates with buprenorphine provides relief from the original pain without the high that opiates produce.  Patients who were switched from opiates to buprenorphine to manage pain reported being clear-headed and energetic – in other words, these individuals are back to the way they felt before taking opiates.

Because buprenorphine is approved for use only for treating “opiate use disorder,” the use of it for pain management is considered “off label.”  Here are a couple of interesting ramifications of the off-label use:  First, doctors who prescribe buprenorphine for off-label use are not required to complete the training and receive the waiver that is required for prescribing for addiction treatment.  Second, insurance may not reimburse for the use of buprenorphine for off-label use.  So while it is easy for a doctor to prescribe buprenorphine to individuals addicted to opiates to manage pain, insurance issues may prevent the drug from being affordable.

Our Take on Medication Assisted Treatment for Opiate Addiction

Although we are philosophically inclined to minimize the use of drugs as much as possible for any type of treatment, buprenorphine and methadone are proven to keep opiate addicts alive.  We suggest that treatment programs adjust their paradigms of treatment and recovery to include the use of opiate replacement drugs in their programs, regardless of the extent that individuals participate in the counseling components of treatment.