Medication Assisted Treatment for opioid addiction
CSAM aligns itself with the NIH consensus statement of 1997, which defines opioid addiction as a chronic disease, and calls for increased access to long-term treatments. [1] The World Health Organization also supports maintenance pharmacotherapy as a way to save lives and prevent HIV transmission among persons who are opioid dependent, and has declared buprenorphine to be an ‘essential medication.’ [2] Maintenance pharmacotherapy with psychosocial treatment (currently known as Medication-Assisted Treatment or MAT) represents the medical standard of care. Methadone maintenance treatment (MMT) was the first and still the most common form of such treatment in the US.[3]Since 1965 MMT has been shown to reduce mortality, lower criminality, enhance functionality, and to reduce the incidence of seroconversion to HIV.[4-6] The NIH Consensus statement called for increased access to maintenance pharmacotherapy, and reduction in the severely restricting regulations that have governed methadone maintenance. [1] The
Office-based opioid pharmacotherapy using sublingual buprenorphine
A major change enhancing treatment options for opioid dependence was the Drug Addiction Treatment Act of 2000 (DATA 2000), enabling office-based use of certain approved opioids in the treatment of opioid dependence.[8] This law is sometimes nicknamed the ‘buprenorphine law’, because under its restrictions the only two medications allowed in office-based treatment by qualified physicians are two formulations of sublingual buprenorphine that were approved by the FDA in 2002 for the treatment of opioid dependence, Suboxone® and Subutex®. These medications have been scheduled as three by the DEA because they have a better safety profile in cases of over-dosing than full agonist opioids such as methadone.
Office-based treatment is a major breakthrough in access to care for individuals who find it burdensome or impossible to attend a highly regulated specially-licensed outpatient clinic for their daily dose of methadone. Office-based opioid treatment (OBOT) also holds the promise of integrating health-care needs and thus improving the quality of care. Now, under DATA 2000, opioid-dependent patients may receive opioid pharmacotherapy treatment with their own physician and using sublingual buprenorphine in a familiar setting integrated with their medical and psychiatric care. Instead of daily visits to a specialty clinic, the patient can now fill his or her prescription at a local pharmacy. Not surprisingly, in controlled comparisons of clinic care versus OBOT, the OBOT was significantly better in patient satisfaction.[9] Analyses of the use of office-based sublingual buprenorphine in the US to date show that compared to MMT, buprenorphine treatment reaches patients who are better educated, more likely to be employed, and more likely to have taken prescription opioids as their main drug of abuse when compared to MMT. Addiction treatment professional societies have trained thousands of physicians throughout the country in the office-based treatment using sublingual buprenorphine, and seventy thousand patients have taken advantage of this treatment. [10, 11] Based on these reports of OBOT patient characteristics, it would be expected that private insurance coverage is more likely to be at issue in OBOT than in a more disabled clinic population. Prescription opioid abuse has been on the rise in the
Length of treatment in opioid dependence
As with other chronic illness, opioid addiction has a wide range of severity of presentation. Since naturally occurring withdrawal from opioids is not in itself life-threatening, some addicted persons withdraw with no treatment at all, and may remain abstinent for years with ongoing self-help or mutual help meetings. When more severe symptoms are anticipated, patients may choose to undergo a gradual medically supervised withdrawal (MSW) in an inpatient or outpatient setting, followed by full addiction treatment, psychosocial support and monitoring. Many patients and family members still focus on ‘detox’ or ‘rehab’ and wish for a quick correction or cure to addictive behavior and dependence. However, the pattern of addiction is chronic. [14, 15]Although safe, forms of medically-supervised withdrawal for opioid dependence, even when enriched with psychosocial services, do not usually result in long-term abstinence, and relapse rates are high.[16, 17] Even when every effort has been made to enhance psychosocial treatment during and after the actual MSW, the drop-out rates and death rates remain high, and outcomes are better on maintenance than other treatments. [18, 19]No matter the method of detoxification, and no matter the criteria for patient selection for detoxification, poor long-term outcomes ( 40-60% relapse by six months, approaching 90% by 12 months) suggest a chronic disease - perhaps a long lasting abstinence syndrome - that is not being addressed by MSW of any kind. [20][[21] [14, 22] [16, 23] A recent CSAT treatment guide about the use of detoxification treatment in addiction medicine points out that detoxification is successful if it has fostered the patient’s involvement in full, long-term treatment.[24] This benefit of maintenance over MSW has been shown for sublingual buprenorphine treatment. In one placebo controlled study retention in treatment was 75% for maintenance, and 0% after a six day detoxification.[25]Because of this high relapse to opioid abuse, addiction specialists recommend that even when MAT is used for medically supervised withdrawal, maintenance be readily available as a backup in case of threatened or actual relapse. [26, 27]
Buprenorphine maintenance treatment (BMT)
Methadone maintenance has been used since 1965, with long-term use conferring lasting and increasing benefit over time. [4, 28] [29, 30]Sublingual buprenorphine was developed in the 