Medication-Assisted Treatment Can Lower Risk of Opioid Addiction Relapses
Medication-assisted treatment may be the most effective strategy for preventing potentially fatal relapses for individuals recovering from opioid addictions, according to national experts at a University of Miami Miller School of Medicine symposium held May 21 at the Shalala Student Center.
“Medication strategies work for many people with opioid abuse disorder,” said Edward V. Nunes, M.D., professor of psychiatry at the Columbia University Medical Center.
While some are able to avoid relapses on their own, a much higher percentage of patients are successful when given methadone, buprenorphine or naltrexone, which substitute for opioids or block their effect, he added.
Nunes was a keynote speaker at the full-day symposium, “Fighting Opioid Addiction: Integrating State of the Art Science Treatment into Patient Care,” sponsored by the Miller School of Medicine, Miami Center for AIDS Research, Florida Node Alliance of the National Drug Abuse Treatment Clinical Trials Network, the UM Clinical and Translational Science Institute, and the L&L Copeland Foundation.
In his talk, “Treatment for Opioid Use Disorder: State of the Art,” Nunes pointed to similarities with the HIV epidemic of the 1980s.
“This is a chronic disorder with a high mortality rate that affects 2.5 million Americans,” he said. “There are challenges every step of the way, from diagnosis to treatment to abstinence.”
The deadly impact of opioids
Viviana Horigian, M.D., associate professor of Public Health Sciences and executive director of the Florida Node Alliance, welcomed approximately 150 attendees to the symposium, which focused on the impact of prescription painkillers, heroin and potent synthetic opiates like fentanyl.
“Across the country, the opioid epidemic is reaching staggering proportions with about 175 deaths every day,” Horigian said. “Nationally, just 21 percent of people with opioid use disorder are receiving treatment.”
To address the problem, the federal government has issued a number of recommendations, including improved surveillance and reporting, expanded access to medication-assisted treatment (MAT) and implementation of risk-reduction programs such as clean syringe exchange programs, she said.
Keynote speaker Frederick Altice, M.D., M.A., professor of medicine and epidemiology at the Yale School of Medicine and Yale School of Public Health, noted the similarities between the opioid and HIV epidemic of the 1980s, including a slow public health response, blaming the individual, and the lack of initial public interest in a major public health problem.
“Prescription pain killers started the opioid epidemic, but it has transitioned to heroin and deadly synthetics like fentanyl,” he said. “We have learned that detoxification alone doesn’t work. This is a brain disease that needs to be treated with long-acting injectable medication.”
As U.S. Surgeon General Jerome M. Adams, M.D., M.P.H., said in a video message shared with attendees, “Opioid addiction touches families in every community. My brother Phillip went to prison for crimes due to his addiction. I couldn’t prevent or fix his illness, so stopping this epidemic is very personal for me.”
A global need for pain relief
While opioid abuse is an epidemic in the U.S., globally there is a vast unmet need for pain relief, according to Felicia Knaul, Ph.D., professor in the Department of Public Health Sciences and director of the Institute for Advanced Study of the Americas.
“More than 61 million people around the world have serious health-related suffering every year, and most have no access to pain relief or palliative care,” said Knaul, who served as chair of the Lancet Commission on Global Access to Palliative Care and Pain Relief. “That is an incredibly inequitable condition, as alleviating the suffering can be done at a modest cost at the primary care level. No child with cancer should die in agony.”
In the U.S., Knaul said a balanced approach toward pain relief is essential. “The supply and marketing of opioids should be monitored, and all health personnel should receive basic training, and follow evidence-based practices for prescriptions.”
Citing a recent “call to action” in Lancet, Knaul said, “It is time for the inequity in pain relief to be remedied. All actors should be held accountable to close this divide.”
Leveraging drug court
At Miami-Dade County Drug Court, treatment rather than imprisonment is the goal for individuals with substance abuse problems who are arrested for serious crimes, according to Circuit Court Judge Jeri Beth Cohen.
“We work closely with clinicians at Jackson Health System to monitor treatment and compliance,” said Cohen. “Last year, we had 1,100 admissions, including 240 with opioid use disorder. Many of those individuals also have trauma or mental illnesses as well.”
With the support of a $2.5 million grant from the Substance Abuse and Mental Health Services Administration, an on-demand clinic is now available for detoxification and stabilization through MAT, Cohen said. “We have been able to retain them in treatment, rather than sending them to a residential facility with very cost-effective results.”
Patricia Ares-Romero, M.D., chief medical officer at Jackson Behavioral Health Hospital, also emphasized the importance of integrating MAT into the drug court program. “We see that maintenance helps patients put their lives back together, regain their children, return to school, and get new jobs.”
Local approaches to the opioid epidemic
Opioid intervention strategies need to be adopted to the varying needs of rural, suburban and urban communities, according to John T. Brooks, M.D., lead medical epidemiologist, Division of HIV/AIDS, Viral Hepatitis, STD and TB Prevention, at the Centers for Disease Control and Prevention.
Brooks noted that the most vulnerable places in the U.S. for opioid overdose deaths are central Appalachia and rural areas of New England and Michigan — mostly white communities with relatively low income and high unemployment rates.
“We also tracked acute cases of hepatitis C (HCV), which are associated with non-sterile injections of opioids,” he said. “After we shared our analysis, state leaders in Kentucky and Tennessee implemented syringe service programs (SSPs) to address both problems.”
In South Florida, Hansel Tookes, M.D., M.P.H., assistant professor of clinical medicine and director of the Miami IDEA Exchange, said SSPs are effective in engaging people who inject opioids, but more studies need to be done on their ability to prevent transmission of HIV and HCV.
Since launching Miami-Dade’s needle-exchange program last year, Tookes said 150,000 used syringes have been taken off the streets, and more than 1,000 boxes of Narcan, an emergency overdose medication, have been distributed to injectable drug users.
“The number of overdoses fell from 2016 to 2017, and we are hopeful that will continue this year,” he said. “Also, we recently launched a new partnership with the Miami-Dade County Health Department so high-risk individuals using injectable drugs can get a direct referral to Jackson’s HIV clinic, allowing them to start anti-retroviral therapy right away.”
Lillian Rivera, Ph.D., M.S.N., RN, administrator of the Florida Department of Health in Miami-Dade County, gave an update on the county’s Opioid Addiction Task Force as well as its HIV/AIDS Task Force.
“We are now in the implementation stage for the recommendations from both groups,” she said.
Another panelist, Sharleen M. Traynor, M.P.H., a doctoral student in epidemiology, emphasized the importance to increasing and standardizing local surveillance to guide public health actions in relation to the opioid crisis.
“We need to monitor events as they happen, so we can respond faster to current trends,” she said.
To close the symposium, José Szapocznik, Ph.D., professor of Public Health Sciences, and co-principal investigator of The Florida Node, moderated a “town hall” discussion with speakers, panelists and attendees, saying, “By sharing information, we can learn about evidence-based strategies to address this national public health problem.”