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Opioid Maintenance: Make New Meds But Keep the Old
In spring 2006, a rare overcrowding struck The Johns Hopkins Hospital. It had barely a bed to spare—not a happy situation for a major medical center. Though many suspected why, it took a proper study to ferret out the real problem. And it was this: A substantial number of hospital patients surveyed reported substance abuse (SA) disorders, either adding to the illness that sent them to Hopkins or as the main reason they came. Arranging discharges for such patients well enough to go home was just short of nightmarish.
The SA situation wasn’t a Hopkins specialty—it continues to flummox every U.S. city’s medical centers. Part of the problem lies in numbers. In 2007, for example, Maryland hospitals admitted more than 69,000 patients for SA treatment. Nationwide, closer to 2 million filled hospital beds. And what the local and national figures reflect is a falling short in medicine’s ability to see the big picture of substance abuse and to keep that picture current.
If the SA difficulty is something of a Venn diagram where neurobiological, social and political issues overlap in one murky triangle, we have to be willing to go into the thick of it, says addictions expert Eric Strain.
There are immediate steps to take, Strain says—electronic records, for example, should help streamline clinical services. But the broader perspective is getting more attention at Hopkins: A new Center for Substance Abuse opened this spring—under Strain’s direction—to advance research and bridge treatment efforts on Hopkins’ two medical campuses. The center is charged, in part, to fill gaps in patient care. But it’s also bent on raising evidence-based treatment beyond a presently high level—the fruit of a half-century of Hopkins research.
“We want to create a research-based model of care for the nation,” says psychiatrist Strain. “But that means bringing an understanding of all the overlapping elements to the care of individual patients.” It’s tailoring to a new degree.
For more than two decades, Strain has taught and researched addictions treatment. From expertise in pharmacology, he became well-versed in the behavioral, policy and economic issues as well as the epidemiology of opioid misuse. His recent book with colleague Maxine Stitzer, The Treatment of Opioid Dependence, was cited as “required reading that shaves years off a steep learning curve for new practitioners.”
We’ve questioned Strain on one issue—maintenance treatment for opioid addiction—to get a feel for SA’s “murky triangle.” Compare older methadone replacement therapy with newer buprenorphine, we asked. Both help keep patients off heroin, for example, or prescription painkillers like oxycodone.
Methadone clinics have stayed full since the 1960s. But Hopkins did many of the primary studies the FDA used in 2003 to approve buprenorphine. Why? Wasn’t methadone enough?
Buprenorphine and methadone have different pharmacologic profiles; it’s not like, say, Zoloft and Prozac, which are closer. Having options is good. There’s a need for both; we prescribe both at Hopkins. But buprenorphine’s main advantages aren’t so much pharmacologic as they are social.
Historically, researchers readied buprenorphine to be available through a delivery system different from methadone’s. Methadone is very safe when used properly but it’s highly regulated; you only get it through special clinics. In the past, some of those weren’t well run. Communities saw that and didn’t want new ones around—not in my neighborhood! Expanding the clinics became extremely difficult, though recently that seems to be changing as government oversight and treatment standards improve.
Buprenorphine was developed for doctors to prescribe from their offices—to have physicians provide mainstream treatment for addictive disorders as part of their practices. We encourage that by offering buprenorphine courses here for professionals. The feeling is that it has a relatively low abuse potential. A high dose of methadone can be fatal in someone not physically dependent on opiates. Buprenorphine has less risk. Also, some patients report that it helps them feel more clear-headed. All of that simplifies things.
What about the shift in drug abuse that caused such a swell?
From the mid-1990s, we’ve seen a dramatic increase in misuse of prescription opioid painkillers. These users are less likely to be poor or homeless; they’re often married and employed and don’t abuse other substances like heroin. It’s a good population for buprenorphine.
Do people on buprenorphine stay with treatment longer than those on methadone?
No. We studied retention; it’s the same. All SA programs have substantial dropout. And no matter which program you’re in, the longer you’re in, the better the outcome.
A last word?
These are medical disorders we’re discussing, and people suffer greatly with them. Simply punishing someone because of abuse is a narrow and inhumane approach. We use other ways to help, and they’re a lot more effective.