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Greater Use of Meds to Halt Opioid Overdose Epidemic Urged

(ĐTĐ) – US addiction experts are urging expanded use of medications to combat the "opioid overdose epidemic" plaguing the country.

In a commentary published April 23 (2014) in the New England Journal of Medicine, National Institute of Drug Abuse (NIDA) director Nora Volkow, MD, and colleagues from other US Department of Health and Human Services (HHS) agencies call upon healthcare providers to expand their use of medications to treat opioid addiction and reduce overdose deaths.

In addition, they describe a number of misperceptions that have limited access to these potentially lifesaving medications.

The reasons include inadequate provider education and misunderstandings about addiction medications by the public, healthcare providers, insurers, and patients. One common, long-held misperception is that medication-assisted therapies (MATs) merely replace one addiction for another ? a view that is not backed by science.

"When prescribed and monitored properly, medications such as methadone, buprenorphine, or naltrexones are safe and cost-effective components of opioid addiction treatment. These medications can improve lives and reduce the risk for overdose, yet medication-assisted therapies are markedly underutilized," Dr. Volkow said in a release.

Between 1999 and 2010, the death rate from prescription opioid overdose in the United States more than quadrupled, a rate that far exceeds the combined death toll from cocaine and heroin overdoses.

Rates of emergency department visits as well as substance-abuse treatment admissions related to prescription opioids also increased markedly during the past few years, as have prescription opioid–abuse costs to insurers.

These health and economic costs are similar to those associated with other chronic diseases, such as asthma and HIV infection, the authors note. These "alarming trends" have prompted the HHS to take multiple federal, state, and local actions, including expanding access to medication-assisted therapies to help patients recover.

"A key driver of the overdose epidemic is underlying substance-use disorder," the authors write. Similar to other chronic diseases, "addiction is generally refractory to cure, but effective treatment and functional recovery are possible."

Part of that functional recovery must involve the appropriate use of existing MATs, including use of methadone, buprenorphine, and naltrexone.

These medications have been shown to reduce the risk for overdose and improve lives, the authors note. In Baltimore, for example, increasingly, the availability of methadone and buprenorphine roughly halved the number of fatal overdoses from heroin between 1995 and 2009.

Many treatment facilities also favor abstinence as the best treatment model for addictions and do not routinely offer MATs. Inadequate dosing when MATs are used is also systemic and further reinforces lack of faith in their use, inasmuch as patients often return to opioids because treatment was ineffective, the authors note.

Other barriers to appropriate use of MATs include both policy and regulatory issues, including limits on the dosages prescribed; annual or lifetime medication limits; initial authorization and reauthorization requirements; and "fail first" criteria that require the use of other therapies first before attempting to introduce an MAT.

As Dr. Volkow and colleagues point out, HHS agencies are now actively collaborating with public and private stakeholders in an effort to both expand access to and improve the use of MATs.

They are also directing efforts toward the development of new pharmacologic treatments for opioid addiction and improved delivery systems for current medications, including the development of nasal sprays.

At the same time, Dr. Volkow emphasizes that it is critical to make sure policies that curb inappropriate prescribing of opioid analgesics not infringe on the critical and even lifesaving use of the same agents when clinically indicated.

Charged with providing access to treatment programs, the Substance Abuse and Mental Health Services Administration (SAMHSA) is encouraging MATs through the Substance Abuse Prevention and Treatment Block Grant as well as through regulatory oversight of medications used to treat opioid addiction. In addition, it has developed an Opioid Overdose Toolkit designed to educate first responders in the use of naloxone to prevent overdose deaths.

"It also gives local governments the information they need to develop policies and practices to help prevent and respond appropriately to opioid-related overdose," she added.

In addition, the Centers for Medicare and Medicaid Services is working to enhance access to MATs through a more comprehensive benefit design, as well as a more robust application of the Mental Health Parity and Addiction Equity Act.

However, the authors point out that success of these strategies requires engagement and participation of the medical community.

The authors report no relevant financial relationships.

N Engl J Med. Published online April 23, 2014. Full article


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