Beyond Supply: How We Must Tackle the Opioid Epidemic

• Published in: Mayo Clinic proceedings Vol. 93; no. 3; pp. 269 - 272
• Main Authors: Srivastava, A. Benjamin, Gold, Mark S.
• Format: Journal Article
• Language: English
• Published: England Elsevier Inc 01.03.2018; Frontline Medical Communications Inc; Elsevier Limited
• Subjects: Addictions; Analysis; Comorbidity; Drug overdose; Health aspects; Heroin; Hospital patients; Mortality; Opioids; Overdose; Patient satisfaction; Public health; United States > US
• ISSN: 0025-6196; 1942-5546
• DOI: 10.1016/j.mayocp.2018.01.018

Strikingly, using nationwide data from US poison control centers,West et al13 found that over 65% of opioid overdoses reported were indeed suicide attempts, and of completed overdoses, the percent of those characterized as suicides climbed to 75%. [...]an "inconvenient truth" may be that many of these opioid overdoses presenting to emergency departments may be unrecognized suicide attempts and that many of the over 66,000 deathsmay indeed be completed suicides. [...]comprehensive evaluation and treatment become even more relevant. Clearly, more thorough evaluations in emergency departments with comprehensive risk assessments are needed, especially given that these patients may be guarded about suicidal ideation in the first place.14 Indeed, efforts to initiate buprenorphine in the emergency department, which independently is being investigated for its therapeutic effects on suicidal ideation, have spread; however,while abstinence outcomes are favorable at 30 days, the therapeutic benefit seems to disappear at both 6 months and 1 year.15 This failure of opioid reversal treatment is important, especially given that at 1 year, 15% of patients rescued with naloxone had died.16 Additionally, lack of psychiatric services and overcrowding at many emergency departments may preclude a comprehensive evaluation; however, target screening of all high-risk patients may identify patients with even hidden suicidal ideation and allow for appropriate triage.14 Most addiction treatment today is centered around time-limited settings without adequate follow-up.17 Although MAT is an important addition to treatment for opioid addicts, it is generally not sufficient for long-term sobriety given (1) the relatively high rates of immediate and short-term treatment discontinuation and (2) that patients rarely are using just opioids.18 In fact, regarding long-term outcomes, methadone may be the only MAT treatment that demonstrates superior abstinence rates, safety, opioid overdose prevention, and treatment retention.18 We recommend that future studies include random assignment to different treatment modalities, assessing abstinence with urine testing and other modalities, psychosocial outcomes, and overall level of functioning for 5 years. In terms of treatment, we suggest a continuing care approach, viewing addiction as a chronic, relapsing disease, but higher quality data are needed.17 For example, in most states, physicians with substance use disorders who are referred for treatment indeed undergo evaluation and detoxification, but they are also monitored for 5 years with frequent drug testing, contingency management, evaluation and treatment of comorbid psychiatric issues, and mutual support groups.19 Outcomes are generally superior, with 5-year abstinence and return to work rates approaching 80%.17,19 Notably, most of these programs do not allow MAT, yet opioid-addicted physicians do as well in the structured, supportive, long-term care model as physicians addicted to other substances.19 Obviously, the threat of professional license sanctions may impel physicians to comply with treatment, butmany of the aforementioned strategies including contingency management, long-term follow-up, comprehensive psychiatric evaluation, and mutual support have demonstrable evidence for addiction treatment in general.19 More resources need to be devoted to addressing the opioid epidemic, particularly on the prevention and also the demand side.