BREAKING THE CYCLE OF OPIOD ADDICTION AND DEATH: AN ARGUMENT FOR MEDICATION-ASSISTED TREATMENT
Opioids are a class of drugs used to reduce pain and have the potential to be misused. A few examples of opioids are oxycodone and morphine. Both prescription and non-prescription opioids are very addictive, which is why they are commonly abused, and often lead to overdose. Opioids produce a feeling of euphoria caused by the increase in levels of dopamine. The medications attach to the parts of the brain that control emotions and pain. Your brain gets used to this feeling and becomes dependent on the drug, causing the addiction (Howard).
In order to understand the current opioid epidemic, it is important to note just how we got here. In the 1800s, doctors used morphine to relieve patients’ pain. The amount of morphine was not controlled, so patients easily acquired more morphine, leading to their addiction. The use of opioids has become more diverse over the years. For example, soldiers used opioids for pain and alcoholics used opioids to alleviate hangovers (The Prescription Opioid and Heroin Crisis). In the late 1990s, pharmaceutical companies began reassuring people within the medical community that opioids would not become an addictive pain reliever, so medical professionals proceeded to prescribe them at a greater rate. The increased amount of opioids prescribed unfortunately led to the misuse of the medications (Opioid Overdose Crisis).
This was only the beginning of the opioid epidemic. In the years that followed, fentanyl, which is a lot more addictive than morphine, began being used by hospitals for patients who were in severe pain. Most fentanyl is made in labs and is sold on the streets. A study done by the journal JAMA stated that opioids are not needed in order to relieve pain, there are other medications that can be administered to alleviate severe pain (Howard).
Today, when someone arrives at an emergency because of a drug overdose, they are usually revived with Narcan, and may or may not be given a referral for additional recovery that directs the patient to seek further treatment with a medical specialist. Patients are often immediately discharged from the hospital after being administered Narcan, a medication that blocks the effects of opioids and revives a patient from an overdose. These patients are left vulnerable and have a strong desire for the drug they were using, which causes them to use again and return to the emergency room.
The opioid epidemic – and how to deal with those who overdose – has become a serious concern and a hotly-debated topic in the United States. According to the Centers for Disease Control and Prevention, more than 72,000 people in the United States died from drug overdoses in 2017, which equates to nearly 200 overdose deaths per day. That number was up from 2016, which was a record year with approximately 64,000 overdose deaths in our country. The CDC estimates that at least two-thirds of drug overdose deaths in 2016 and 2017 were linked to opioids. (Lopez, German. 2017 Was the Worst Year Ever for Drug Overdose Deaths in America.) With this growing number of deaths linked to opioids, it’s time for politicians, health care professionals and drug treatment experts to come together to execute a solution.
Imagine coming into the emergency department as a patient because you have misused and overdosed on opioids. You will likely be administered Narcan, which is commonly used to counter the effects of opioid overdose. If this treatment is successful, in today’s healthcare climate, you will very likely be released without any referral to further primary care or ongoing medications to help with drug withdrawal, such as Suboxone. What commonly happens next is that the addict does not change their behavior. They go back to their same lifestyle, and often end up back in an emergency room, where the cycle repeats itself. Some action needs to be taken to improve the success rate of addicts who overdose. One possible solution is medication-assisted treatment.
Medicated-assisted treatment was first introduced at Yale New Haven Hospital in 2009 and has been a model for multiple EDs throughout the United States. Patients that show signs of opioid withdrawal are prescribed medications by emergency physicians, including buprenorphine, methadone, naltrexone, or naloxone. However, most hospitals, including those previously mentioned, prescribe Suboxone; a combination of buprenorphine and naloxone. Suboxone helps alleviate withdrawal symptoms and physiological cravings, allowing a patient to comfortably focus on therapy without being distracted by withdrawal symptoms After receiving medication, MAT patients are referred to a MAT provider for further medications (Initiating Medication-Assisted Treatment for Patients Presenting With Opioid Withdrawal). Also, under federal law, patients must receive counseling, such as behavioral therapy. According to Dr. Evan Schwarz, an assistant professor of emergency medicine at the Washington University School of Medicine, “pairing buprenorphine with counseling is a winning combination (Robeznieks).” It was discovered that if patients coming into the emergency room experiencing withdrawal were offered the opportunity to receive medication and met with a counselor or a peer coach and given the opportunity to find out to learn more about treatment programs, 75% of the time they were enrolled in treatment 30 days later (Initiating Medication-Assisted Treatment for Patients Presenting With Opioid Withdrawal).
To illustrate this very serious issue and how medicated assisted treatment might have prevented the death of a young man, I’ll share the story of my former teacher’s son, who I’ll call “Ryan” to protect his identity. Ryan was a young, vibrant and successful young man on the surface. His family did not even know that he was misusing opioids. Ryan was in college, living on his own and was leading a seemingly normal life. On a Monday morning, my teacher was called because Ryan didn’t show up for work. When he arrived at Ryan’s apartment, he found his son dead of a drug overdose. This was both shocking and soul-crushing for my teacher and his entire family. In the days that followed, my teacher learned that Ryan had gone to a local emergency room for an overdose treatment two days before he was found dead. Ryan was treated with Narcan and released the following day. As often happens, Ryan went home and continued his drug use, which led to his death two days later.
In this case, medication-assisted treatment might have saved Ryan. One of the reasons that opioid addiction is so powerful is that users feel like they must keep using the drugs in order to stave off withdrawal (Lopez, German. There’s a Highly Successful Treatment for Opioid Addiction. But Stigma Is Holding It Back). As a drug user becomes immune to a certain level of drug, he or she needs more of the drug to avoid withdrawal symptoms like body aches and nausea. This causes the addict to seek out street drugs like heroin or other street drugs to avoid these debilitating symptoms. This may not help them achieve their usual high, but it helps to keep them level.
In addition to the very human element of drug addiction and overdose deaths, most large cities in the U.S. are seeing a sharp rise in healthcare costs related to opioid abuse. For example, hospitals in New York City reported approximately 45,000 emergency room visits for opioid patients in 2017. In addition, the New York City mayor is seeking a $500 million lawsuit against opioid manufacturers and distributors. As a whole, in 2015, the economic cost regarding opioid abuse was at $504 billion in the United States. Between 2009 and 2015, the average cost of treating an overdose victim in an ICU increased by 58%. As the addiction worsens, victims return in poor conditions and need longer stay periods. The average cost throughout 162 academic hospitals was $92,400 per patient in an ICU. Also, about 8 billion was spent on criminal justice related costs, basically a cost to state and local governments. Even worse, the relapse rate for drug addicts is about 45% within 3 years of prison release (Lamagna). Although an abundance of money is being spent in many areas for opioid victims, not enough money is being spent to help stabilize the patients and deal with the issues within the emergency department. If overdose victims were directed to medication-assisted treatment, they would be far less likely to return to the emergency room, or even worse, end up in a hospital’s ICU. This could save hundreds of thousands of dollars in medical costs.
Many experts believe that medications like Suboxone can stop the addiction cycle by fulfilling the addict’s cravings and lessening withdrawal symptoms. In medicated assisted treatment, Suboxone is administered in a medically supervised setting. It does not produce the euphoric high, but it reduces the risk of relapse, since the user doesn’t have to endure withdrawal symptoms. Suboxone can be prescribed long-term, or in some cases, the patient may be weaned off the drug over time. In any case, medicated assisted treatment seems to have a far greater likelihood of success than releasing a drug addict 24 hours after they overdose, only to see them relapse and continue their drug habit.
It appears that research now backs up the claim that medication-assisted treatment could be the answer to stopping – or at least decreasing – the opioid epidemic. Various studies, including systematic reviews of the research, have found that medication-assisted treatment can cut the all-cause mortality rate among addiction patients by half or more. (Lopez, German. There’s a Highly Successful Treatment for Opioid Addiction. But Stigma Is Holding It Back)
One of the reasons that there’s a reluctance to promote medication-assisted treatment for overdose victims is the stigma surrounding drug use. Many people do not view addiction as disease, but simply as a choice someone made. Public health officials refer to addiction as a disease, but everyday Americans cannot seem to do the same. The issue is that when looking at other diseases there is no question if medication is an answer. If a medication came out for another disease – like cancer or Lou Gehrig’s disease – that would cut mortality by half or more, it would be considered a huge victory and would be scaled quickly. Yet, in the case of drug addiction and overdose, we are reluctant to promote and scale medication-assisted treatment.
There are several examples of other post-overdose programs that some hospitals are trying in an effort to support relapses and returns to the emergency room. At Boston Medical Center, Project ASSERT helps emergency department patients who demonstrate risky alcohol and drug use behavior to access treatment and care. It has offered referral and treatment for drug and alcohol screening for more than 60,000 patients in the emergency room since 1994. The program is staffed by licensed alcohol and drug abuse counselors, which enables each patient establish close relationships with the staff, helping to build trust and provide emotional support. Project ASSERT staff members are always present in the emergency department. If a patient arrives, they have a non-judgmental conversation to make it easier for the patients to pursue a healthier lifestyle. If the patient agrees to receiving treatment, then they are connected to a substance abuse treatment center. They are also referred to health and social services, as well as primary care services, so patients have complete access to care, even after they have left the emergency department (Project ASSERT).
In 2016, the State of Maryland, which had one of the highest rates of opioid-related emergency room visits, established the Community Outreach Addictions Team (COAT) in Wicimico County to do outreach in emergency rooms. What makes this program unique is that COAT peers are all recovering addicts which allows them to connect better with those who are facing a similar struggle. At Sailsbury University in 2017, a formal evaluation of the Community Outreach Addictions Team program was conducted by the Business Economic and Community Outreach Network (BEACON), which concluded that “COAT is performing at a 62.68% higher rate than the nation in assisting drug users into rehabilitation at specialty facilities.” BEACON also found that the return on investment was 7:1. This meant that for every dollar spent on COAT, caused the community to save a total of seven dollars. Within the first half of 2017, while Wicomico saw a 42% decrease in the amount of deaths related to drugs and alcohol, the state witnessed only a 20% decrease. Also, Wicomico observed a 50% decrease in fentanyl-related deaths, while State averaged a 70% increase (Community Outreach Addictions Team Evaluated).
There is some evidence that there is growing support for medication-assisted treatment. The Hazelden Betty Ford Foundation, which is one of the top drug treatment centers in the United States, used to subscribe to an abstinence-only approach to addiction recovery. In 2012, however, the Foundation announced that it would provide medication-assisted treatment. One of the Foundation’s employees, Evan Hansen, was initially against medication-assisted treatment, he says, because it “was nothing more than substituting one drug for another.” Today, he argues in support of medication-assisted treatment because “science overwhelmingly supports that it is the best form of treatment for opioid addiction.” (Lopez, German. There’s a Highly Successful Treatment for Opioid Addiction. But Stigma Is Holding It Back)
As more organizations like the Hazelden Betty Ford Clinic educate and speak out in support of medication-assisted treatment, there is hope that further scaling of this treatment, combined with more effective counseling and support services, could have a positive impact on stemming the opioid epidemic in our country. It is time for us to abandon the moral stigma of drug addiction and understand that it is a disease which can and should be treated like any other. If we accomplish that, then medication-assisted treatment could be the answer to the most gripping epidemic that has faced our country.
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