Treating the Opioid Epidemic: Medications & Approaches
NOVEMBER 01, 2018
Lindsey Jennings MD, MPHAside from facing stigma and access hurdles, patients with opioid use disorder face the challenge of recovery. However, programs that use counseling approaches in combination with US Food and Drug Administration (FDA)-approved medications can achieve greater success. One such program is in effect at the Medical University of South Carolina (MUSC).
In an exclusive interview with MD Magazine®, Lindsey Jennings, MD, MPH, and Carolyn Bogdon, MSN, FNP-BC, of MUSC discussed the 3 FDA-approved medications available to treat opioid use disorder as well as the different treatment approaches that can aid patients on the road to recovery.
[Editor’s note: Transcript slightly modified for readability.]
MD Mag: What are the best strategies for combatting the opioid epidemic in terms of medications and treatment plans?
Bogdon: At this point, we know of 3 evidence-based, FDA-approved strategies for treating opioid use disorder. We know those are the standard of care, and [they] are typically what we are able to offer patients—the combination of medication as well as the psychosocial counseling piece that goes along with it.
The medications are methadone, buprenorphine, and naltrexone. Methadone is a full opioid agonist that can only be dispensed in a methadone clinic or opioid treatment program. In the state of South Carolina—for the entire state—there are only 16 of those, and so patients have to drive every single day to go get their medication.
[Methadone] has been the standard treatment for years for opioid addiction. For a long time, it was the only medication we knew of and had available. It’s effective when dosed correctly, and when patients work their program of recovery [to be] involved in counseling, and [follow] everything [that] goes along with it [their program]. Sometimes patients need that daily structure to go along with their medication.
Then there’s buprenorphine, which is a partial opioid agonist and newer than methadone. It has been available as of 2000 [and it is] available not just at opioid treatment programs, like the methadone clinics, but also as an office-based treatment (OBOT).
Patients do not necessarily have to go to the opioid treatment program every single day to get their medication. They can receive a prescription for their medication just as you would receive a prescription for insulin for your diabetes.
They can get that in their primary care office if their primary health care provider has received the training to prescribe this medication through the buprenorphine waiver training program. Patients see their provider, get a prescription for the medication, and [have] co-occurring psychosocial counseling.
Then there’s naltrexone, which is an opioid antagonist. There is a pill form of it, but typically, for opioid addiction, we find the best results when we use the long-acting injection. That’s a 1-month injection that patients receive every month from a provider’s office. They also [have] counseling with that as well since addiction is a disease that we typically [treat with counseling and medication].
Opioid use disorder is one of the only diseases of addiction that [has] medications to treat it. There are some for alcohol as well, but a lot of other substance abuse disorders do not have medications to offer [in conjunction] with counseling.
Jennings: We talked a lot about the medications we can use to treat patients, but the other thing that we are doing in our [MUSC] program is giving patients free Narcan [naloxone] kits. Narcan is a reversible agent for patients who have injected opioids. It is used when patients have such a toxicity that they are unresponsive or not breathing, and it is something that can reverse the effects of opioids so the patient is awake and breathing again.
From a harm reduction standpoint, Narcan is a [hugely important] tool. It does not treat [opioid addiction] long-term, but in the short-term, it can save lives. There has been a lot of movement across the country, and within the state of South Carolina, to increase access to Narcan.
MD Mag: What does an effective approach to treatment look like for an opioid-addicted patient?
Jennings: For the emergency department, specifically, our workflow for patients is that everyone comes in through triage by a nurse. There is some information that our triage nurses gather from all patients, and our screening tools identify patients that might be at risk for having opioid use disorder.
While everything else is going on in the emergency department, [medical professionals are] confirming whether the patient actively wants to get into treatment—which is the reason why they are in the emergency department—or if they are [in the emergency department] for an unrelated reason, such as pneumonia or a cough. We have patient navigators in the background reviewing all those nursing charts, and then they will talk the patient through the SBIRT model. We [perform that process] for all substance use disorders.
If [a patient is] using opioids as well, then we have a conversation about buprenorphine. We will discuss what the medication is, what the follow-up looks like, [and what] they can expect when taking the medication. Then, we are able to get a referral so they can be seen the next day in one of our clinics. That way, they can see a provider who can then continue the medication, write a prescription, and then get them to the appropriate counseling services as well.
Bogdon: In our program, patients are only given a 1-time dose of the medication, and that is to get them feeling comfortable and feeling well [as they come] out of acute opioid withdraw so that they can arrive to their next day appointment with a provider and a specialized addiction treatment program or primary care practice that can provide these services to them.
Patients are not given a prescription for [buprenorphine]; it is just a 1-time dose. [Because of this practice,] over 80% of patients show up [at their appointments] the next day, which is pretty remarkable. The fact that we’re seeing over 80% showing up to next-day appointments is something we are proud of since we are able to help get those patients into treatment.
MD Mag: What do you feel still needs to be done in order to help alleviate this epidemic and help those patients who are addicted?
Jennings: From a health care provider’s standpoint, [we need to] continue to have an open mind about these patients and try to avoid the stigma. [We need to] increasing access to care, particularly for underfunded patients. Depending on the state, that can be very difficult. Screening within medical systems would be another way of identifying these patients and getting them to the treatment they need.
Bogdon: I would echo all that [and add that we need to] appreciate that this is a chronic disease, similar to diabetes or high blood pressure. [Consequently], it does require chronic management, whether it be medication, counseling, or very commonly, a combination of both.
It is really important for patients, the general public, health care providers, and health care workers to all realize and appreciate that just like patients with diabetes may stop taking their medication and eat a lot sugar, patients with opioid use disorder or addiction may [also go off their treatment regimen]. They may relapse, and if and when that happens, we want to be able re-engage with them, get them back into treatment, and continue treating their chronic disease.
European Trial to Investigate Exocrine Pancreatic Insufficiency in Patients with Type 2 Diabetes Mellitus