EDITORIAL: What the U.S. needs to treat addiction as the medical crisis it is

Nov. 09--The President's Commission on Combating Drug Addiction and the Opioid Crisis released its final report last week, and it included some welcome discussion about addressing the nation's epidemic of opioid addiction as the medical and public health crisis that it is.

The commission, led by New Jersey Gov. Chris Christie, recommended a number of measures to make it more likely that someone with an addiction will receive treatment -- specifically, medication-assisted treatment, which is backed up by science. During a presidential administration not known for making thoughtful decisions based on the best available evidence, we appreciate the commission's emphasis on employing evidence-based practices to ensure people with addictions receive the most effective treatment.

"[T]he use of [medication-assisted treatment] has been associated with reduced overdose deaths, retention of persons in treatment, decreased heroin use, reduced relapse, and prevention of the spread of infectious disease," the commission report reads.

But although one of the keys to abating the opioid addiction crisis will be found in medicine, the nation still has a long way to go before it will actually be approaching the crisis as a medical one.

If the nation as a whole were addressing the addiction epidemic as a medical crisis, more people would be receiving treatment for their substance use disorder, which is a medical condition. And they would be receiving the most effective, available treatment.

According to the U.S. Substance Abuse and Mental Health Services Administration, about 80 percent of people with an opioid use disorder never receive any treatment. Of the portion who do receive some sort of treatment, an even smaller subset receive medication-assisted treatment for a sustained period.

The best available evidence shows that such treatment is most effective when it lasts at least five years, according to Nora Volkow, director of the National Institute on Drug Abuse, the federal government's addiction research arm. But less than 2 percent of people with opioid use disorders are continuing with medication-assisted treatment for at least six months, she said at a recent roundtable for health care journalists in Boston. Policies such as one in Maine, which limits many Medicaid recipients to no more than two years of treatment with Suboxone or methadone, don't help.

"There's absolutely no evidence that one or two years is sufficient," Volkow said.

One important step toward addressing the opioid epidemic as a medical problem would be increasing the portion of people with addictions who are diagnosed with a substance use disorder.

"This is a disease that has been tremendously undiagnosed, and undiagnosed within our health care system," Michael Botticelli, who served as the director of the Office of National Drug Control Policy during the Obama administration and now runs the Grayken Center for Addiction at Boston Medical Center, said. (Botticelli visited Bangor in 2014.)

In its report, the president's commission calls on health care providers to screen patients for substance use disorders and refer them to treatment. Currently, the top source of referrals for substance use treatment is the criminal justice system, Botticelli said during the Boston session with health care journalists.

"We let people progress to their most acute condition," he said. "Often, that's criminal behavior. We are missing opportunities every step along the way."

Even when people with addictions receive medication-assisted treatment -- which, combined with behavioral counseling, is considered the gold standard of care for an addiction -- treatment options are limited. In the past four years alone, the FDA has approved 15 new medications to treat diabetes, which, like substance use disorder, is a chronic disease. For opioid use disorder, there are primarily three approved medications available -- methadone, buprenorphine (known commercially as Suboxone and Subutex) and naltrexone (known commercially as Vivitrol).

There are promising new formulations in the works going through the FDA approval process, Volkow said. There's also ongoing research into the development of a heroin vaccine and the use of brain stimulation to treat addiction.

But there's no new treatment that will be available in the short term -- even though the availability of more than three medications to treat opioid use disorder will be critical in fighting the nation's addiction epidemic.

"We have three medications," Volkow said. "We could benefit from many more because not every patient responds to them."

The president's commission set out the right solutions but much more work needs to be done to make them available and effective as the nation struggles to treat substance abuse disorder.

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