Getting treatment for an opioid use disorder will hopefully in turn reduce the number of overdoses and deaths related to opioid use. Despite increased public awareness about the dangers of opioids, the epidemic continues in the US. What can we do to counter this deadly trend? The numbers are striking.

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October 31, 2019
THE CONTINUING OPIOID EPIDEMIC
thesoberworld.com/2019/10/31/the-continuing-opioid-epidemic
Getting treatment for an opioid use disorder will hopefully in turn reduce
the number of overdoses and deaths related to opioid use.
Despite increased public awareness about the dangers of opioids, the epidemic continues
in the US. What can we do to counter this deadly trend?
The numbers are striking.
• About 68% (more than 47,000) of the more than 70,200 drug overdose deaths in the US
in 2017 involved an opioid
• 36% of those 47,000+ deaths were attributed to prescription opioids
• In 2017, the number of overdose deaths in the US involving opioids prescription and
illegal—was 6 times higher than in 1999
• On average, 130 Americans die every day from an opioid overdose
Increased attention to deaths related to opiate use has spurred action. Many states
have developed mandates to intervene to prevent deaths. There also has been increased
response to the need for more caution in the prescribing of opioids.
“We are in the middle of an epidemic, with hundreds of people losing their lives
every day,” said Shelly F. Greenfield, MD, MPH. “But we are fighting each day to
develop tools and policies that will stem the loss of life.” Greenfield is the director of
McLean’s Alcohol and Drug Abuse Clinical and Health Services Research Program.

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Improving Reaction to Emergencies
Public health advocates and clinicians have embraced the use of naloxone for opioid use
emergencies. Trained laypersons can administer this opiates antidote. Partly through the
intervention of the FDA, over time, prices for naloxone treatments have been greatly
reduced.
Recently, distribution of intranasal naloxone to those struggling with opiate addiction—
and to their loved ones—has become an overdose prevention strategy. Intranasal
naloxone can be administered by anyone. This can revive an overdosed individual while
formal medical treatment is sought.
Getting to the Root of the Problem
Intranasal naloxone is an important and potentially lifesaving intervention for someone
who has overdosed on opiates. Nonetheless, it is not a substitute for addressing the
underlying problem of addiction.
Hilary S. Connery, MD, PhD, is the clinical director of McLean’s Substance Use
Disorder Division. She is working to enhance follow-up care for those who have received
emergency treatment for opioid use.
“A lot of patients who get naloxone rescue don’t engage in followup treatment,” she said.
“Obviously, opioid use disorder is a lethal illness, but it’s a lethal illness for which we have
very good treatment that will save lives. It’s time to create a community-wide
collaborative where rapid response and rapid initiation of treatment are available to
patients, post-overdose, for all who are willing to seek treatment and are open to that.”
Getting treatment for an opioid use disorder will hopefully in turn reduce the number of
overdoses and deaths related to opioid use.
Treating Opioid Use Disorders with Medication
Many evidence-based treatments now exist. These include medication based and
therapeutic approaches to treat substance addiction.
Methadone is one type of medication that can be effective for opioid use disorders. It
stimulates pain-relieving receptors in the brain similarly to other opiates, such as
oxycodone.
There’s an important difference between methadone and opioids that are often misused,
like heroin. Methadone’s effect takes place more slowly and lasts longer. As a result,
people in treatment with methadone typically do not experience a euphoric “high,” nor do
they experience the cravings associated with the drug effect wearing off quickly.
Studies have demonstrated that methadone treatment is associated with a lower risk of
opioid misuse, death, criminal activity, and unsafe behaviors that can lead to infection
with HIV or viral hepatitis.

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Methadone use is highly regulated. It only takes place at specially licensed treatment
programs that offer intensive treatment. This approach may reduce the risk of patients
using medication for nontreatment purposes. It can also be an obstacle to people who
want to be treated, but don’t want to go to a methadone treatment program.
Buprenorphine was introduced, in part, to offer an office-based treatment option for
patients. Like methadone, it stimulates the opiate receptor in the brain to reduce drug
cravings. It also blocks the opiate receptor to reduce or eliminate the effects of misused
opiates. Buprenorphine treatment has similar benefits to moderate doses of methadone,
in terms of reducing opiate use and mortality rates.
Buprenorphine is commonly taken as a pill placed under the tongue. A new, long-acting
version can be injected monthly to help individuals stick to the treatment and to maintain
steady blood levels.
Unlike methadone, clinicians who have completed specialty training can prescribe
buprenorphine. This allows people to receive a prescription in their community provider’s
office. Many people find this preferable and more convenient than treatment at a
methadone program.
About 68% (more than 47,000) of the more than 70,200 drug overdose
deaths in the US in 2017 involved an opioid. 36% of those 47,000+ deaths
were attributed to prescription opioids
A third medication option is naltrexone. It is a blocker of the opiate receptor. This means
that it reduces or eliminates the effects of other opiates by not allowing them to stimulate
the brain’s opiate receptor.
Naltrexone for opioid use disorder is most commonly administered as a long-acting,
monthly injection. This helps reduce vulnerability to relapse when a person might skip a
daily dose. Long-acting,injectable naltrexone treatment is associated with similar
reductions in opiate use to those seen with buprenorphine treatment.
One challenge with naltrexone treatment is the need to establish an opioid-free period of
1-4 weeks before taking the first dose. This can be an overwhelming obstacle for many
people struggling with opioid use disorder—unless they are provided with adequate
support.
Inpatient and residential treatment programs can provide a structured setting for
detoxification and stabilization before starting medication treatment. Residential
treatment for opioid use disorders is associated with less use of heroin and other drugs,
lower rates of heroin dependence, fewer injection-related health problems, reduced
involvement with crime, and improved overall health. There is also strong scientific
evidence of benefit from particular forms of talk and behavioral therapies delivered by
well-trained clinicians.

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Policy around the country regarding treatment is starting to change. In Massachusetts, for
example, collaborative efforts between the Baker Administration and state legislators
have increased patient access to residential treatment. It is important for people
struggling with opioid use disorder to recognize that they may now be able to access
treatment with insurance support.
Struggling with Multiple Conditions
People with opioid use disorder are at very high risk of suffering from depression—five
times more than people without opioid use disorders. They are also at increased risk of
death by suicide. This is partly due to the very high occurrence of depression and other
mental health conditions seen among those with opioid use disorders.
Clinicians offer a broad array of options that have been proven to help with these common
but serious conditions. These treatments may include different types of medications and
therapy.
Overcoming the Stigma of Addiction
Effective interventions are too frequently underutilized. This is often related to a belief
that addiction represents a failure of willpower or a flaw in character.
Most genetic studies of drug and alcohol use disorders reveal that at least 50% of the risk
for these conditions is heritable. This means that it can be passed on in families, like eye
color or diabetes. This argues for a strong biological basis for these chronic diseases,
calling for clinical treatment based on best medical practices.
People do not die of character flaws. They die of illnesses. If you or a loved one is
struggling with addiction to drugs or alcohol, speak to your own or your loved one’s
physician, or consult one of these resources:
• National Institute on Drug Abuse: Information for patients and families
• SAMHSA’s Behavioral Health Treatment Services Locator
• McLean Hospital addiction treatment programs
• SAMHSA’s National Helpline: 1.800.662.HELP
Rocco A. Iannucci, MD, is the program director of Fernside, a McLean Hospital
Signature Addiction Recovery Program. He is also an instructor in psychiatry at
Harvard Medical School. Dr. Iannucci specializes in the treatment of people with severe
substance use disorders and those with multiple mental health conditions. He has
published on the treatment of addiction in residential programs, and on cocaine misuse.