October 2021 Fatal Misconceptions and The Reality of Using Medications to Treat Opioid Use Disorder

10/29/2021

Medication assisted treatment (MAT): The very mention of this topic is likely to spur responses across the emotional spectrum from extremely positive to pure hatred. The order of conversation topics to now avoid are religion, politics, and medications to treat opioid addiction. While it may prove an uncomfortable topic to discuss, it is imperative to do so given West Virginia’s opioid epidemic.

West Virginia has consistently led the country in overdose death rates, including a nearly 50% increase in 2020 as a result of the COVID-19 pandemic. We lost 1,377 citizens to drug overdoses, 1,179 of which involved an opioid and 1,095 specifically to synthetic opioids (mainly fentanyl).1 This article attempts to clarify common misconceptions with opioid addiction treatment and why medications are used to treat this deadly disease.

Myth #1: Opioid addiction is simply a choice and those who misuse opioids do not deserve treatment.
Opioid use disorder is a neurologic disease where individuals pathologically pursue opioids. It involves multiple factors including societal, genetic, and importantly neurobiological. The human brain’s natural reward systems are significantly altered in patients who struggle with this disease. What historically would bring us joy, be it warmth, a good meal, or a precious hug from a child, no longer registers the same in the brain of someone who has an opioid addiction. Ask anyone who struggles and they will tell you that they are not the same person they once were, a reality that is supported by multiple brain imaging studies. While some may fatalistically argue that these people should “get what’s coming to them,” empathy and humanity dictates that they should be offered some form of effective treatment.

Myth #2: The cure to opioid addiction is abstinence and drug rehab.
The traditional approach was to treat opioid addiction similarly to alcohol abuse. Detox the patient, place them in a residential rehab program, and then direct them to attend 12-step meetings. Unfortunately, this has proved to be a largely ineffective strategy for the past 50+ years with appalling relapse rates hovering around 90%. The affliction of opioids is so great that opioid addiction was long considered a “hopeless disease” before the advent of effective medications. While detox and rehabilitation facilities fail many patients, they are guaranteed to lower a person’s tolerance to opioids. Not taking opioids results in lower physiologic tolerance which subsequently raises the risk for a fatal overdose in the event of a relapse, notably in the first month following treatment.2 To this point, the American Society of Addiction Medicine (ASAM) does not consider opioid withdrawal management alone to be a viable treatment method.

Myth #3: Medication-assisted treatment (MAT)/Medications for opioid use disorder (MOUD) are experimental, unproven treatments.
MAT is the gold standard of opioid addiction treatment given the overwhelming amount of evidence to support their use. Listed in the order of U.S. Food and Drug Administration (FDA) approval are three medications considered the first line of treatment: methadone, naltrexone, and buprenorphine. Each has pros and cons, and all have different mechanisms of action on opioid receptors. Methadone works as a full opioid receptor agonist, activating the human opioid receptor similar to other opioids and effectively satiating “opioid hunger.” Naltrexone is a full antagonist that blocks opioids from binding to receptors, thus preventing euphoria. This mechanism is longer-acting but identical to naloxone (Narcan), the rescue medication used to reverse an opioid overdose. Lastly, buprenorphine exerts its effect as a partial agonist, somewhat binding to opioid receptors but also blocking other opioids from causing euphoria and fatal overdoses.

The evidence for the use of these three medications is robust. These medications have been shown to lower the use of illicit opioids, decrease criminality, reduce healthcare costs, and increase treatment retention.3 Most importantly, methadone and buprenorphine have proven to reduce opioid overdoses, a benefit that naltrexone has yet to show. Many have championed the use of naltrexone, namely Vivitrol, as the ideal treatment for opioid addiction. Unfortunately, it is difficult to initiate, harder to maintain compliance, and has yet to show a clear survival benefit, which results in naltrexone to generally be considered an inferior treatment to methadone and buprenorphine in individuals at the highest risk for fatal opioid overdoses.

Myth #4: MAT is just trading one drug of abuse for another.
This is partially true in that electing to take MAT is a trade of sorts: MAT trades illicit opioids like fentanyl that kill more than 1,000 West Virginians yearly for FDA-approved medications that keep people alive. As society does not discourage diabetics from taking insulin or cancer patients from chemotherapy, then why are blanket prohibitions placed on medications often proven to be more effective at reducing death? Actual overdoses on methadone are rare and are virtually non-existent for buprenorphine unless sedatives such as alcohol or benzodiazepines are involved. Patients who take these medications generally look and feel stable. They are able to work and have families. They are not pathologically pursuing opioids to the point of self and societal destruction. Today, the use of MAT is even a safe and accepted treatment for physicians who want to continue to practice medicine after recovering from opioid addiction. If MAT is a trade, it is a sound trade that saves lives.

Conclusion

Ultimately, West Virginia is at a crossroads on how to combat the opioid crisis. West Virginians can either embrace the use and evidence behind MAT as the gold standard of treatment or continue to pursue failed strategies. Rejecting the use of medications will assuredly result in a continued lead in the nation’s overdoses deaths. By following the evidence, there will be a decrease in citizen deaths, fewer incarcerations, a reduction in infectious diseases, and an overall healthier state. Future generations will see the decisions made today and judge if enough was done to help those who suffer from this disease.

Jeremy D. Hustead, M.D. is an Assistant Professor at the WVU Medicine Rockefeller Neuroscience Institute’s Department of Behavioral Medicine & Psychiatry. Dr. Hustead serves as the President of the West Virginia Society of Addiction Medicine (WVSAM), the state chapter of the American Society of Addiction Medicine (ASAM). He has no financial connections or disclosures with any pharmaceuticals or outside treatment programs.

References:

Drug overdose deaths increase in West Virginia, nationwide. MetroNews (July, 2021) Retrieved October 27, 2021: https://wvmetronews.com/2021/07/14/drug-overdose-deaths-increase-in-west-virginia-nationwide/#:~:text=West%20Virginia%20had%201% 2C377%20deaths%20in%202020%20related,involved%20opioids%20and%201%2C095%20deaths%20involved%20synthetic%20opioids.
Opioid overdose risk during and after drug treatment for heroin dependence: An incidence density case–control study nested in the VEdeTTE cohort. Drug and Alcohol Review. 40(2):281-286, 2021.
Medication-Assisted Treatment (MAT). Substance Abuse and Mental Health Services Administration (SAMHSA). Retrieved October 27, 2021: https://www.samhsa.gov/medication-assisted-treatment

Contact Information

Jeremy D. Hustead, M.D.