Exploring the Complexities of Opioid Use Disorder
One of the few topics that everyone seemed to agree on during the 2016 election was that there is an opioid epidemic in America and we need to do something about it. No one argued with the numbers, no one argued with the urgency.
Throughout the United States, opioids have seeped their way into rural and urban communities, affecting people of all ages and socioeconomic backgrounds. Public health officials are calling the opioid epidemic the worst drug crisis in our country’s history. According to the CDC, 91 people will die of an opioid overdose today, that’s more than quadruple the rate of 1999. The ubiquitous features covering the opioid epidemic that are overwhelming the news cycle do nothing to incite hope: HIV outbreaks in Indiana due to intravenous drug use, a rise in infant dependency, and a surging overdose rate.
Is this a tireless battle we’ve already lost?
Not in the hearts and minds of mental health providers who are able to find glimpses of optimism in the advancements of medical technology, shining light on possible solutions to the epidemic. Opioid use disorder (OUD) has the most advanced pharmacotherapy to aid in its treatment out of any other substance use disorder.
Let’s try to understand the complexities of treating a use disorder
OUD is a biopsychosocial disorder; it is a confluence of biological, psychological, and social factors interacting to create and maintain a disorder.
The argument is that it isn’t enough to treat just one of these factors, all three - biological, psychological, and social factors - must be addressed. If an individual suffering from OUD is unemployed, has low job prospects and suffers from anxiety, the impetus to adhere to treatment is significantly lowered and a need for an escape is increased.
How do we treat OUD?
Medication-assisted therapy (MAT), is the use of medications in combination with counseling and behavioral therapies to treat substance use disorders and prevent opioid overdose. Common medications used in MAT include methadone, buprenorphine, and naltrexone.
MATs, “whole-patient” approach has shown to be highly successful in the treatment of OUD, leading people to get a handle on their disease and their lives.
Methadone programs have a high success rate overall. Individuals who are incarcerated that come into the system already connected to a methadone program and continue with this method of treatment while incarcerated have a 91% likelihood they will maintain their MAT upon release. For general populations, adherence to a methadone program has shown correlations to lowered recidivism rates and higher quality of life.
If we look at naltrexone, we begin to see how outside factors influence treatment. Naltrexone is an opioid antagonist first approved by the Food and Drug Administration (FDA) in 1984. Its properties made it a promising treatment for heroin users: it blocks the subjective effects of heroin, has a small number of side effects, and does not build tolerance. A person can be on naltrexone for an indefinite period of time without sacrifice to their health or well-being. However, orally administered naltrexone has a high dropout despite the objective usability of the drug.
The biggest downfall of naltrexone is the need to take it every single day. It’s an active choice the individual must make every day. And human behavior dictates that no one makes the right, healthy, decision, every single time they are faced with a choice. Of course, for those of us not contending with an OUD, our unhealthy choices may not seem as dire. But for those suffering from OUD, having to decide, “Today I don’t need opioids” every single day is not ideal. Some days it’s an easy choice, other days it’s a struggle.
There are moderating conditions driven by outside motivations, however, that can lead to a higher adherence rate. Involvement with the criminal justice system and running the risk of returning to prison and facing the loss of employment, are two examples. Higher adherence rates can also be the result of a country’s strict drug laws and in turn high stake consequences of opioid use, as exemplified by Russia who has some of the strictest consequences for opioid users and consequentially higher than average treatment compliance rates. Russia also has a high rate of young adults with OUDs residing with their parents who are then able to ensure that medication is taken every day. The more restrictions, the higher the likelihood of medication adherence. However, this is usually a short-term solution considering that the goal of treatment is generally for the individual to maintain a healthy lifestyle while meeting developmental norms, such as independence. It’s just not realistic to expect an adult will forever be able to have someone else ensuring they comply with treatment day in and day out.
A solution to this predicament is a treatment for OUD that doesn’t necessitate a pill every day: vivitrol. Vivitrol is an intramuscular injection of naltrexone that lasts 4 weeks. Similar to the orally administered version, it has few side effects, does not build tolerance, and its main effect is to block the μ-receptors, thus blocking the rewarding effects of opioids. Studies have shown that individuals receiving vivitrol had a 68% treatment adherence versus 39% in their control counterparts. Individuals who have been placed onto vivitrol while incarcerated showed significantly lower relapse and recidivism rates. While vivitrol cannot account for all of the factors that may lead a person to relapse, it is proving to be a useful tool in combatting OUDs.
For individuals who are more likely to remain in treatment with an opioid agonist, there are long-acting options that don’t necessitate daily medication compliance. Only approved by the FDA this past May, probuphine is an implant that provides a matrix diffusion of buprenorphine over a six month period. A controlled trial of 163 participants found that individuals using probuphine had significantly increased treatment adherence, lowered cravings, and both subjective and objective clinical improvements in the participants. While there is still a significant amount of research to be done, probuphine has excited the OUD treatment community as a promising form of treatment.
We must continue to explore all options
Every person is different, as are their treatment needs. Fundamental to progress, and to each glimmer of hope, is an appreciation of the epidemic’s complexities. None of these treatments are all encompassing and there is still much to be learned, especially in addressing the psychological and social factors that contribute to OUD. One important element is approaching victims of opioid addiction with compassion. All available tools must be explored, and the selected treatment method tailored to fit the needs of the individual.