What does mental health have to do with mitigating the opioid epidemic? Isn’t it a problem for substance disorder programs, or addiction doctors?
Well not really, if you consider the rates of opioid use and opioid use disorder (OUD) in patients seen in the community-based, non-profits in NYS providing mental health services. Among Medicaid insured adults about one in three (1/3) people seen in a public mental health clinic in the past year have been prescribed opioids or carry the diagnosis of OUD. That’s from Medicaid data, not from screening and detecting opioid use and dependence in these clinical settings, where rates of identification have yet to align with prevalence.
Still, doesn’t that mean we need to refer these patients to substance treatment centers and doctors? Also, not really, if we face a couple of facts: First, we already know that when we try to refer a patient with a serious mental illness (SMI) to another program, even to primary care, they just don’t go. Like giving a business card to a homeless person on the street. Second, do we really imagine these other programs have any capacity to take on new patients, or if they do the wait time is months if it is to see a physician. In other words, the patient before us in a mental health clinic is our patient, substance disorder and all.
The key clinical question then is: how are we going to keep this person alive for the next 6 months, twelve months? By decreasing the risk of drug overdose, and overdose deaths. Which continue to rise in this country.
The greatest lifesavers, evidence shows us, is the prescription of Medication Assisted Treatment (MAT) and the free and abundant dispensation of Naloxone (Narcan – the reversal drug).
We may not have been those physicians who, in the 1990s and early 2000s, inadvertently fostered the opioid epidemic wanting to reduce their patients’ pain and buying into the false advertising that opioids were not addicting. But we are the physicians (and prescribing nurses) today who can help end the opioid epidemic and save lives.
The actions psychiatrists and prescribing nurses in mental health offices and settings can take that will save lives are: 1) the prescription of buprenorphine in mental health and primary care settings and 2) the dispensation of naloxone at those same settings (or in conjunction with local health departments).
Buprenorphine
Buprenorphine can be a critical lifesaving medication treatment because those taking it are far less likely to overdose and die, unlike those that are not prescribed this medication.
Despite being released as an FDA approved medication in 2002, the use of buprenorphine (Suboxone and others) today remains limited, especially considering the rising death toll from the opioid epidemic and the safety and effectiveness of this medication.
Buprenorphine is a partial agonist to the opioid receptor (it is simultaneously a receptor antagonist). As an agonist, this medication binds fiercely to opioid brain receptors thus blocking the uptake of or displacing other opioids, making ingestion of heroin or opioid analgesics by someone with OUD not worth the effort or expense.
It is more difficult to get “high” or overdose on buprenorphine, unless it is mixed with other, non-opioid substances like benzos, alcohol and sedatives. Preparations of buprenorphine have diversified. First there was the sublingual pill, then the dissolvable film, and more recently a monthly subcutaneous injection or a set of four tiny sustained release implants under the skin that can last up to six months.
In past years, street diversion of buprenorphine was limited. More recently, however, this drug has gained greater street value as a type of “insurance” for opioid users in the event they cannot obtain their usual drug supply or want to withdraw or reduce their tolerance. We can this of this use (and diversion) as a form of “harm reduction”.
There are concerns, sometimes voiced, about the potential burden and risk of prescribing buprenorphine in mental health offices. There is the required training and DEA waiver, both burdens. There is the prospect of even higher caseloads for doctors and nurses. There is worry about how people in opioid withdrawal might behave, including their threatening clinicians for prescriptions. These are problems to be mitigated or solved, but not by eluding the needs of the patient we are serving.
I will not discuss naltrexone (Vivitrol) here, another effective, FDA approved medication, preferring to focus on the two agents that can save the most lives in the next year.
Naloxone
Naloxone is first and foremost a lifesaver. EMTs, police and (increasingly) friends and families of people using opioids should have ready access to naloxone nasal spray in the event of an opioid overdose. The nasal spray avoids the “needle barrier”, fears many have about the use of syringes, even auto-injection syringes. Countless lives have already been saved by naloxone.
Naloxone acts immediately and effectively, reversing respiratory arrest and loss of consciousness. It is like the AED (automatic defibrillator) of the world of opioid addiction.
Most states permit pharmacies to dispense naloxone without a prescription. But it can be pricey for individuals and families without insurance or facing a high co-payment (I paid $40 for a 2-vial package). Having naloxone available at no cost is essential if we are to save more lives in the foreseeable future. No one recovers from opioid addiction if they die from an overdose.
I do not mean to suggest that medications alone are the best approach to treating opioid use disorder. Like any complex and persistent condition, a combination of medication, therapy, motivational approaches, family engagement and mind-body interventions (like exercise, nutrition, yoga, meditation) are more likely to achieve enduring results. That said, buprenorphine and naloxone remain our most immediate and effective interventions to keep people with OUD alive, so they can live long enough to enter recovery.
Opioid use and dependence are of epidemic proportions in this country. But we have beaten back many an epidemic. Think of smallpox, polio and cholera; of how we have reduced morbidity and mortality from driving deaths and tobacco; and how, with a groundswell of public support, we beat back the AIDS epidemic.
Effective solutions to the opioid epidemic exist. Mental health clinicians need to join in this effort. After all, many people using and dependent on opioids are in our mental health centers day after day – even if we imagine they are not.
Lloyd I. Sederer, MD, is Adjunct Professor at the Columbia School of Public Health; was for 12 years the Chief Medical Officer for the NYS Office of Mental Health, the nation’s largest state mental health agency – and continues there as Distinguished Psychiatrist Advisor; and Contributing Writer for Psychology Today, the NY Journal and Washington Independent Review of Books & the NY Daily News, among other publications. He was Medical Editor for Mental Health for the HuffPost, where over 250 of his posts were published. He has served as Mental Health commissioner for NYC; Medical Director/EVP for McLean Hospital, a Harvard teaching facility; and as Director of Clinical Services for the American Psychiatric Association. He has written hundreds of articles on mental health, the addictions and book, film, TV and theatre reviews, and has published a dozen books.
Dr. Sederer is the 2019 recipient of the Doctor of the Year award from The National Council on Behavioral Health. He is a Co-Founder of SessionTogether. He recently created and now directs Columbia Psychiatry Media.
His new book, now in paperback, is The Addiction Solution: Treating Our Dependence on Opioids and Other Drugs (Scribner, 2018). Look for his next book in 2020.
