Today concluded over 35 hours of training in the Mayo Clinic Tobacco Treatment Specialist Certification (Oh, yeah, these thoughts are my own and in no way reflective of the course). While in this course, my peers (including a variety of professionals: dentists, pharmacists, PhDs, RNs, etc.) and I learned everything we needed to assist clients in the cessation of tobacco. This course included everything from the neurobiology of nicotine dependence to the use of motivational interviewing.
There were two, overarching themes, however, that remained constant throughout the course: nicotine addiction is a chronic disease and success is largely dependent on the use of nicotine replacement therapy and counseling. Sure, there is stigma associated with any addiction; but, at least in the medical community, most would advocate for the use of a patch, gum, Chantix, or any other medication that would allow the patient to quit his or her smoking habit. That is to say, healthcare professionals aren't entirely surprised when you say that medication-assisted treatment can double or, even, triple patient outcomes. So, why is it that these same professionals cringe at the thought of medication-assisted treatment for opioid addiction? Is it because opioid addiction is fundamentally different, as a chronic illness, or that this kind of treatment has been shown to be ineffective?
Chronic disease is a disease state that persists for a long time. Most definitions seem to indicate that chronic disease is something lasting 3 or more months and unable to be cured with medication. Drug addiction is a brain disease resulting in the compulsion to seek drugs. This occurs despite knowledge of the health effects. As with other chronic diseases, relapsing in nature (such as: diabetes, asthma, etc), cure is not the goal, management is. We know that alterations occur in the brain, primarily in the reward pathway. We also know that brain scans reveal alterations in those areas implicated in judgment and decision-making. If you were to explain this to many healthcare providers, they'd likely get annoyed with telling them something they already know. You see, like with tobacco, many of us are coming around to the idea that addiction (in all forms) is a type of disease. There is still work to be done, but where a breakdown in logic seems to occur is in the management of that disease. See, giving insulin to the diabetic or nicotine patches to the smoker are without controversy. Why is it that, with the same understanding of the chronic disease model, the illness of opioid addiction is viewed as something entirely different? You often hear the patient on buprenorphine/naloxone (Suboxone) described as someone that "isn't clean, just addicted to something else instead of heroin". (American Society of Addiction Medicine, 2011) Is medication-based treatment fundamentally different or less effective in opioid addiction? In short: no. The rate of relapse in this population is about the same as other chronic diseases, and even lower than something like hypertension (McLellan, O'Brian, Lewis, et al., 2000). Pharmacologically, the treatment isn't so different from tobacco cessation. Suboxone, for instance, has a similar mixed agonist-antagonist mechanism of action as Chantix does in nicotine dependence. Adverse effects in Suboxone treatment are similar to placebo, so arguments against its safety don't much hold. Maybe, then, it is merely ineffective in treatment? Guess again. Double-blind studies show buprenorphine and naloxone in combination and buprenorphine alone reduce cravings and opioid use. In one study, 17.8% in buprenorphine monotherapy tested negative for opiates, combination therapy indicated 20.8%, while placebo resulted in only about 6% testing negative (Fudala, Bridge, Herbert, et al, 2003).
Tobacco use in the United States has largely declined year-to-year. This is largely credited to a number of initiatives (like education and taxation), including a shift in treatment philosophy. Compare this with retail purchases (per capita) of methadone, hydrocodone, and oxycodone increasing 13-fold, 4-fold, and 9-fold, respectively in 2007 (Keyes, Cerda, Brady, Havens, & Galea, 2014). Or consider that in 2010, the sale of prescription opioids had peaked and, at this time, enough had been sold to medicate every adult in America with five milligrams of hydrocodone, every four hours, for one month (Keyes, Cerda, Brady, Havens, & Galea, 2014).
Until we remove the stigma associated with opioid addiction, view it from the chronic disease lens, and treat it accordingly; then we will continue to see the death toll rise and relapse rates remaining constant. A disease in which 2 million Americans struggle with, kills 29,000, and costs nearly $56 billion yearly is one that demands intervention. Action begins with open-mindedness and the admission that we, as a country, are failing.
American Society of Addiction Medicine. (2011). Public Policy Statement: Definition of Addiction. Retrieved from: policy-statement/public-policy-statements/2011/12/15/the- definition-of-addiction
McLellan AT, O'Brien CP, Lewis D et al. (2000). Drug addiction as a chronic medical illness: Implications for treatment, insurance and evaluation. Journal of the American Medical Association 284:1689- 1695.
Fudala P J, Bridge T P, Herbert S, Williford W O, Chiang C N, Jones K, Collins J, Raisch D, Casadonte P, Goldsmith R J, Ling W, Malkerneker U, McNicholas L, Renner J, Stine S, Tusel D. Office-based treatment of opiate addiction with a sublingual-tablet formulation of buprenorphine and naloxone. New England Journal of Medicine. 2003;349(10):949-958
Issaiah1332
3 Articles; 47 Posts
Interesting points. I would say that the cure is worse than the disease if and only if, the outcomes are worse. As it stands now, drugs like Suboxone seem to be saving lives. I think that as long as we are "treating" something, and we truly mean the definition of that word, then we should consider it medicinal and accept the idea that addiction is another disease in mental health.
Your last question is the one I have the most trouble with, because it's a truly difficult question and may not have comfortable answers. I think dependence is absolutely going to be a consequence of anything other than short-term opioid therapy. The fact is that we are not very good at treating pain. We don't have a lot of other options. Prescribers are terrified many times and will randomly discontinue a patient's prescription, which is just asking for their transition to street opioids. So, I think we need to get better at weaning patients off, exploring other pain options, and pairing this therapy with counseling.
As I said in another post, I live in the state with the most opioid overdoses in our country (WV). I've lost many friends to the epidemic. So, I've written a lot on the subject, work with the population, and try my hardest to stop it. But I keep wanting to know what makes us special. Here is what I hypothesize: We are a poor state with poor access to care, our sectors are largely labor intensive and, as a consequence, increases the likelihood of injury, and all of this leads to poorer mental health. So, someone misses the primary prevention that may have thwarted the development of a chronic pain disorder or the get hurt on the job. They get prescribed opioids. Poor economy, poor circumstances, and poor outlook means risk factors for addiction, as they begin to use their medication as a coping mechanism. So, addiction happens. In the ones that aren't addicted, their prescription is easily accessed by other friends, family, and kids.
If we pair counseling with longer-term opioid therapy (they're never really meant for chronic pain), then we may be able to develop healthier coping strategies and the earlier identification of the signs of addiction.