Gold standard for opioid treatment has gotten cold shoulder

If addiction is a disease, a wise psychiatrist once asked, where are all the doctors?

We told you recently about an interesting, and perhaps tragic, convergence of events:

• Drug offense arrests in California have plunged 85% — from 137,054 in 2014 to 20,574 in 2022, according to data from the California Department of Justice,

• While drug overdose deaths have more than doubled — from 4,519 in 2014 to 10,410 in 2022, according to data from the California Department of Public Health.

A flood of fentanyl — a synthetic opioid far more powerful than heroin and morphine — into the nation’s illicit drug supply has driven the huge spike in overdose deaths, even as Prop. 47 reduced a great many drug-related offenses from felonies to misdemeanors, keeping a great many low-level drug offenders out of jail.

The money saved on incarceration was to pay for effective addiction treatment, among other things — which makes the tepid embrace of one of the best drugs for treating opioid addiction puzzling.

Buprenorphine binds to the brain’s opioid receptors, blunting powerful cravings, reducing withdrawal symptoms and providing safety in case of overdose. It’s considered the gold standard for opioid treatment — addiction being a medical condition, after all, which can be managed with medication — but data from the California Department of Public Health show that buprenorphine prescriptions dropped at several points over the last decade, even as deaths were skyrocketing. They’re picking up as of late, but doctors are still wary.

“If we want to know why buprenorphine isn’t well used, look at the federal government,” said an impassioned Dr. Matthew A. Torrington, an addiction medicine specialist in Culver City.

“We took the antidote to opioid withdrawal and craving and we put it behind a  glass door for 20 years,” he said. “Historically, if you want to prescribe this medicine, the doctor had to undergo eight hours of training, then the DEA will come to your office and scare the hell out of you, and after all that, you could only treat 30 patients.”

As of this year, the feds eliminated these barriers — barriers that don’t exist for prescribing actual opioids, mind you — but the damage is done, Torrington said.

“I have stable patients on this medication, trying to convince their primary doctors to continue the prescription, but the primary doctors don’t want to do that,” he said. “They’re afraid. There’s opioid hysteria surrounding all controlled substances.”

If Torrington could wave a magic wand, “I would enact true parity, where people could get access to comprehensive, individualized, multimodal treatment over time,” he said. “Primary care, psychiatry, addiction medication, shoes, socks, healthy food, mind-body activities. I would stop treating people like (expletive) because they have a psychiatric or addiction problem. I’d make sure they had a place to stay and get care as long as they need it — forever, if they need it.

“Some people can figure it out and make it work. Some can’t, and they die, and we seem to be OK with that.”

A spokesman from the CDPH said the buprenorphine prescription data doesn’t provide the full picture of who gets medication-assisted treatment, as it doesn’t track methadone or naltrexone, other drugs for medication-assisted treatment. The pandemic has also ushered in changes to prescribing that will increase access to these medications.

Torrington, who’s also opioid committee chair for the California Society of Addiction Medicine, expects to see a modest increase in buprenorphine prescriptions in 2023, the first year that the stringent requirement for doctors has been dropped.

But he rails that he must adjust care plans to what insurance companies will pay for — something ICU doctors don’t have to do — but he has hope nonetheless.

There have been giant steps forward in the last decade, he said: The Affordable Care Act ensures that everyone can access medication-assisted treatment (even if they’re still wary of using it). No one graduates from medical school today without training in addiction. And while we seem to be in something of a societal collapse, he’s confident that, too, shall pass.

Eventually, we’ll carve out a place for people who are broken and damaged. “I’m incredibly hopeful,” he said.

Source: Orange County Register