As our society continues to struggle with opioid use disorders and diversion of opioid pain medication, several strategies here in New York State have proven helpful. The duty to consult the online Prescription Monitoring Program prior to prescribing controlled substances has resulted in a 90% drop in doctor shopping and a 15 % reduction of opioid medication prescriptions overall. Public awareness of the problem has increased as a result of State and Federal awareness campaigns for physicians, other prescribers and the public, education initiatives by medical societies, and consistent articles by the press. Physicians and other prescribers in New York State have participated in many voluntary educational activities regarding safer opioid prescribing and screening and intervention for substance use disorders, and all licensed prescribers have now completed a mandatory 3-hour CME course (conducted by MSSNY and others) to address these issues. Additional initiatives to educate prescribers and the public will surely be forthcoming.
Despite these efforts, over the last few years we have seen an alarming increase in the number of accidental drug overdose deaths involving opioids or combinations of drugs including opioids. As we have observed a reduction in doctor shopping and abuse of pain medications (and we need to continue to address this issue), we have seen an increase in heroin abuse. Heroin itself has become more potent as dealers are selling this drug in a purer state with a higher amount of heroin in each dose or “bundle.” Even more alarming, heroin is commonly laced with fentanyl, a highly potent opioid sometimes used by physicians as an anesthetic and for pain management. Individuals are at the highest risk for an overdose when they first start using an opioid; when they switch form of drug, for example, oral to intranasal snorting, or snorting to IV use; or when they switch from one type of opioid to another, such as oral pain medications to snorting heroin. Opioid users are especially at risk when they start using after a period of abstinence (including medical detoxification or withdrawal management) when they have lower tolerance and a misperception about the amount tolerated or needed to achieve a desired effect.
As reports of fentanyl mixed with heroin and reports of fentanyl replacing heroin are increasing over the last few years, the overdose death rate has increased with frightening numbers. Fentanyl has been found in heroin, cocaine and even counterfeit alprazolam. The National Center for Health Statistics now estimates that over 64,000 people died from drug overdoses in 2016, an increase of more than 21% from the previous year. Synthetic opioids (mostly Fentanyl) are blamed for over 20,145 deaths, while 15,446 deaths are the result of heroin and 14,427 deaths the result of opioid pills. In fact, the rate of overdose deaths in teens aged 15-19 has sharply increased in 2015 after seven years of stable or declining rates in this age group. Fentanyl and heroin are the main causes of these overdose deaths. New York City saw a huge increase in accidental overdose deaths in 2016 (1374 deaths) compared to 2015 (937 deaths). Unintentional overdose deaths in New York City have increased for seven years in a row, from 8.2 per 100,000 residents in 2010 to 19.9 per 100,000 in 2016, a 143% increase. Most of these overdose deaths involved heroin and nearly half involved Fentanyl.
Some steps have been taken to increase access to care, including federal and state funding for drug treatment programs. However, many programs in New York State do not have access to medication assisted treatment (“MAT”). Some programs are philosophically opposed to MAT, viewing a patient who uses MAT as not abstinent. Many patients and families share a similar viewpoint and may view prescription medications for opioid use disorders as continued substance use/abuse. These well intended but misguided perceptions are often reinforced by drug treatment program staff and by peers in 12-step programs who may be opposed to MAT.
In addition, there is a shortage of access to MAT. Many methadone programs have long wait lists. Although there are more than 32,000 prescribers authorized to prescribe buprenorphine, most of these eligible prescribers don’t prescribe at all or prescribe to only a few patients. Possible causes include stigma against persons with substance use disorders and those who treat substance use disorders and provider fears related to screening and prescribing medications for substance use disorders. Some providers fear extra liability, management of difficult patients, and possible stigma for their practice. Further, public and private payors usually don’t pay primary care physicians to treat substance use disorders and payments for screening and brief interventions are inadequate for the time and effort involved. Too often a physician wants to offer MAT but cannot find available and appropriate substance use treatment programs due to wait lists and geographical limitations. Most psychiatrists and psychotherapists seem to fall into two camps, those who treat addictions and those who don’t. While some experience and expertise is needed to provide good addiction care, 30-50% of patients with psychiatric diagnoses also have a co-occurring substance use disorder, and 30-50% of patients with a substance use disorder also have another co-occurring psychiatric disorder. It would be beneficial for all mental health professionals to address substance use disorders more routinely in their practices, including the use of MAT when appropriate.
There are currently four medications available for MAT for opioid use disorders: methadone; buprenorphine; monthly injectable naltrexone; and naloxone for overdose prevention. Due to the high rate of overdose deaths in New York, particularly in New York City, Long Island and other areas, overdose prevention should simply be another component of MAT.
Methadone is an opioid agonist with a 52+ year evidence base of experience and effectiveness. As methadone saturates and binds to opioid receptors, the reward of using other opioids (the high) is taken away, and withdrawal symptoms and cravings for opioids are alleviated. The data is clear that patients who choose methadone maintenance have lower chances of dying, using IV or other drugs, engaging in criminal activity, or contracting HIV or Hepatitis C and they experience better outcomes in employment, overall physical and mental health, and social functioning. In addition, there is a low risk of overdose death for patients who are on methadone maintenance while the opposite is true for patients who may take methadone for pain management, where there is a high risk of overdose death. However, there remains a high stigma against methadone and methadone can only be prescribed for opioid use disorder at a licensed methadone treatment center. It is often difficult for patients to attend a methadone maintenance treatment program every day or even a few times per week.
Buprenorphine is an opioid agonist-antagonist, which binds to opioid receptors to stimulate them like other opioids, but also blocks the receptors. A patient on buprenorphine may experience relief from withdrawal symptoms and may experience less or no cravings for other opioids. With methadone and buprenorphine, a patient with opioid use disorder often feels a sense of well-being because either drug offers a safer, longer acting replacement for the opioids that they were abusing. Buprenorphine is usually combined with Naloxone, a potent opioid antagonist, which reduces the risk of tampering with the buprenorphine and using it intravenously. Buprenorphine itself is taken sublingually, dissolves under the tongue, and is not absorbed well if swallowed. Naloxone itself is not absorbed well sublingually, but if a patient tries to use the combination medication by IV, the Naloxone is quickly absorbed and blocks the buprenorphine from the opioid receptors and will cause severe withdrawal. Buprenorphine has been used successfully for over 15 years with results similar to methadone and most patients report that buprenorphine has fewer side effects than methadone.
Some may question the use of methadone or buprenorphine maintenance and consider this merely a substitute for heroin or opioid pills. However, methadone and buprenorphine offer stabilization and elimination of the usage/high and withdrawal cycle that persons with opioid use disorder cannot break. Although various psychosocial strategies such as inpatient or residential rehabilitation program, intensive outpatient programs, individual drug counseling, 12 step groups and various combinations may work for patients with opioid use disorder, most patients who stop using opioids end up using again within a year. Some reports place the rate of returning to opioid usage as high as 80-90%. Comparison studies show that MAT combined with psychosocial strategies is more effective that psychosocial strategies alone. Although some results are mixed, MAT combined with psychosocial strategies appears to be more effective for most patients than MAT alone.
Naltrexone, a potent opioid antagonist, is available in a daily oral form and monthly injectable form. The oral form is largely ineffective for opioid use disorder because patients simply stop using it when they decide to return to opioid abuse. Data shows that the monthly injectable form will result in longer periods of abstinence because the medication will block all or most of the effect from opioids if taken. However, there is little long-term data of effectiveness and the studies that demonstrate effectiveness were largely from a population in prison or on probation/parole so it’s not clear how effective Naltrexone IM will be in the general population. Many patients stop coming for injections and since Naltrexone blocks opioid receptors, it may not be a good choice for patients with complicating medical conditions.
Naloxone is another potent opioid antagonist that has been used in hospitals in IV and IM forms to reverse opioid overdoses. In recent years, its use has increased among police officers, EMTs and other first responders. Pursuant to recent state legislation, the general public can now attend a free training and obtain an overdose reversal kit with one or two doses of IN (intranasal) Naloxone. If someone sees a person who has overdosed on opioids or suspects an overdose, they should administer a dose and call 911; if there is no response, a second dose should be administered. There is essentially no downside to the IN Naloxone and the risk of significant side effects (other than causing withdrawal symptoms) is negligible. Any physician can now prescribe IN Naloxone or a patient can request it without a prescription at many large pharmacy chains. To help with the cost, the State requires prescription plans to cover IN Naloxone and is soon to offer up to $40 savings on co-payments.
Despite best efforts by the medical community, overdose deaths from opioids, particularly fentanyl and related compounds, have skyrocketed across the country and New York State. It is high time to address this crisis by addressing substance use and addiction as both a medical and societal problem. Furthermore, we must embrace medication assisted treatment as an option for all who struggle and seek treatment for opioid use disorders.
Frank Dowling is board certified in psychiatric medicine and addiction medicine, has a private practice in Garden City and Islandia, NY that specializes in the care of emergency responders and healthcare professionals and has served in NYSPA/APA and MSSNY/AMA in several capacities. He currently serves as a member of the NYSPA Committee on Legislation and Advocacy, the Secretary of the Medical Society of the State of New York and a member of the AMA Opioid Task Force. He is a Clinical Associate Professor of Psychiatry at SUNY at Stony Brook School of Medicine.