Medications can treat opioid use disorder. Why do so few take it?
When Daniel Patrick Garrett started using Suboxone three years ago, he spent hours driving to find a pharmacy that would accept his prescription for the treatment of opioid use disorder.
Eight couldn’t or wouldn’t fill the prescription, Garrett recalled. A ninth would, but not accept his discount card, something the uninsured 27-year-old had to use to pay for medication. Finally, at the tenth location, a Kroger about an hour from his house, they were ready to fill the prescription and accept the discount.
“I burst into tears because I was so happy that they filled it out for me,” Garrett, based in Jackson, Tennessee, and director and founder of Tennessee Harm Reduction, said today.
Now he uses methadone, another similar drug. Although he no longer has to make the two-hour round trip to a pharmacy, he must visit a local clinic five days a week to take doses of supervised medication. Although the journey is only about five minutes each way, near-daily traffic (the clinic is closed on weekends) and limited hours can make it difficult. Clients waiting for the clinic can spend up to an hour in line, which can lead to comments from passers-by and stigmatization from the public.
“I wish it wasn’t like that,” Patrick said.
What is drug treatment?
Medication therapy, also called MAT, is a way to treat opioid use disorder. “The prescribed drug works to normalize brain chemistry, block the euphoric effects of alcohol and opioids, relieve physiological cravings, and normalize bodily functions without the negative, euphoric effects of the substance used,” explains the administration of addiction and mental health services.
The two most common drugs used in this form of treatment are methadone and buprenorphine, said Dr. Steve North, a family physician in Asheville, North Carolina, who specializes in addiction medicine. A third option, naltrexone, is less used because it requires patients to completely detox first, according to the National Institute on Drug Abuse.
North explained that buprenorphine is a partial opioid agonist, meaning it occupies brain receptors affected by opioid use without giving the same effects.
“By occupying this receptor site, the craving (for illicit opioids and full agonists) is diminished,” he said. Suboxone, the brand name version of buprenorphine, also includes naloxone, which can reverse an opioid overdose.
Methadone, on the other hand, is a full opioid agonist, meaning it has similar effects to illicit opioids, like fentanyl and heroin, and can cause an overdose, North said. However, methadone is more “regulated” than these illicit options, he explained.
“Because methadone is an FDA-approved drug, the supply is much safer,” North said. “Also, it lasts a very long time in the body, so there isn’t the roller coaster effect of ups and downs that occurs with a shorter-acting drug,” like fentanyl or heroin.
Methadone’s effects last about 24 hours, so patients need a daily dose, North said. Avoiding “highs and lows” means people are stable throughout the day, and methadone also helps reduce cravings, he added.
Studies show that access to drug treatment can reduce overdose deaths: examined heroin overdose death rates in Baltimore from 1995 to 2009 found that overdose deaths dropped by 37% after buprenorphine became available in 2003. Both buprenorphine and methadone have decades of research supporting their use, as the latter was FDA approved in 1972while Suboxone and a similar product, Subutex, were approved in 2002.
That said, according to 2020 data from the National Drug Use and Health Surveyconducted by SAMHSA.
“We’ve heard a lot about structural stigma,” said Sheila Vakharia, Ph.D., deputy director of research and academic engagement at the Drug Policy Alliance. “Methadone and buprenorphine are two life-saving drugs that are treated separately from all other prescribed drugs in this country. Much of the way we handle these drugs creates a stigma that involves having to jump through many hurdles that can deter people from wanting to deal with them to begin with.
What is the impact of barriers on use?
A 2021 study published in the Journal of American Pharmacies Association explained that access to buprenorphine formulations, which require a prescription to access, can be “patchy” due to “perceived and real regulatory constraints, training gaps, stigma and challenges to (the) prescriber-pharmacist communication limit”.
Methadone is a Schedule II controlled substance, meaning it has “a high potential for abuse that can lead to severe psychological or physical dependence,” according to the Drug Enforcement Administration. Other drugs that meet this same standard include Oxycodone and Adderall. For fear that the methadone will be diverted, regulations established by the Department of Health and Human Services, DEA, SAMHSA, state authorities and others require most methadone patients to take their dose daily, in person, Vakharia said.
These steps are intended to ensure that the drugs are used appropriately and to prevent diversion, or the misuse and resale of these substances, Vakharia said, adding that research shows that diversion is “much rarer than people think”. According to a National Institute on Drug Abuse 2021 Report, methadone diversion is most common when the drug is used to treat pain, not opioid use disorder. And when diversion occurs in the latter situation, it is due to “a lack of access to medication…consistent with other findings that 80% of people who report having diverted methadone have it.” done to help others who have abused substances,” the report said. .
Both Vakharia and North said the daily visit structure for methadone can make its consistent use particularly difficult, but it’s important to do so because missing a dose can lead to withdrawal. Sometimes patients have to wait outside, leaving them exposed to the public eye. Johnny Sudds, who has been on methadone since 2014, said having to queue in public adds a sense of “shame”.
“You stand in front of people who can see you. … Everyone knows about the methadone line,” Sudds, 71, said. “They despise us. People try to do something good and they get ostracized.
During the coronavirus pandemic, the Substance Abuse and Mental Health Services Administration relaxed their guidelines allow patients defined as “stable” to receive up to 28 take-home doses of methadone. To meet the definition of “stable” under this policy, patients must meet eight qualificationsincluding “a minimum of 60 days of treatment”, negative toxicology tests and “full adherence” to their treatment plan”, according to SAMHSA.
David Frank, Ph.D., a medical sociologist and researcher at New York University’s School of Global Public Health who has used methadone for 20 years, said his clinic’s policies consider it “stable” and allowed him to receive a month’s supply. doses at home at a time, making it easier for her to achieve goals like earning her doctorate. However, he still sees the impact the daily requirement has on people like Garrett, whose program is open from 5 a.m. to 11 a.m.
“Imagine if you had to go somewhere every day at 6 a.m. how that would interfere with anyone’s life,” Frank said. “It’s ironic because the clinics want you to do things like find a job or go to school, but their very policies make that impossible.”
Despite the barriers associated with each medication, some people who use medication to manage their substance use still see it as life changing. Sudds said methadone use allowed him to quit using illicit morphine, which he had been addicted to since the 1990s.
“Suboxone really stabilized and kept me from going into a meltdown,” said Sessi Blanchard, a community drug policy organizer at VOCAL-NY who still uses some substances in addition to Suboxone. “That was the main benefit. It has definitely allowed me to use less (illegal drugs) because I feel stable. (Because Suboxone contains naloxone), the biggest advantage of using Suboxone is that I have never overdosed on an opioid, which is very rare and quite miraculous.