Buprenorphine Naloxone & Naltrexone
I think the main practical point is that pharmacological treatment of opioid addiction is effective and yet not as easily available as it should be. Not all opioid use disorder (OUD) specialized treatment programs offer medication assisted treatment (I have a somewhat out of date report that in 2017 “only … 35.5% offered any single medication for opioid use disorder treatment. ” This is more recent information
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“Though the benefits of providing medication for opioid use disorder are well-known, only 22% of people with opioid use disorder receive medications. Buprenorphine, one of these medications, helps reduce opioid misuse, decrease risk for injection-related infectious diseases, and decrease risk for fatal and non-fatal overdoses.
“Research has shown beyond a doubt that medications for opioid use disorder are overwhelmingly beneficial and can be lifesaving, yet they continue to be vastly underused,” said NIDA Director and senior author, Nora Volkow, M.D. “Expanding more equitable access to these medications for people with substance use disorders is a critical part of our nation’s response to the overdose crisis.”
Until last year, one barrier was that most doctors were not allowed to prescribe buprenorphine – a special waiver was required. This was a crazy policy reversed by the Biden administration. “the … Fiscal Year 2023 omnibus appropriations bill amended the Controlled Substances Act to eliminate the requirement that clinicians obtain a specific waiver to prescribe buprenorphine to treat opioid use disorder” ” buprenorphine remains a Schedule III controlled substance with restrictions on prescribing.”
Importantly suboxone buprenorphine and opiate antagonist naloxone is also Schedule III. This makes no sense as the naloxone reduces the risk of diversion and the risk that misused buprenorphine will cause an overdose (which is low in any case). Googling for [suboxone overdose] I get links only to buprenorphine overdose statistics (93% of deaths involve another drug too — 50% entanyl — buprenorphine alone about 75 deaths a year). The emergency treatment for opioid overdose is naloxone. The naloxone does not change the effectiveness of buprenorphine when used properly (pill or film under the tongue) but only if it is diverted and injected or snorted.
I have searched for [suboxone diversion]. as with [suboxone overdose] I get only references to buprenorphine. I am ignorant and, in particular, aware of no evidence that suboxone is ever diverted to recreational use or (especially harmful) use by people who are not yet addicted. Yet it is schedule III. Why ?
Aslo diverted Buprenorphine is not necessarily abused. It is also used by people who want to avoid heroin and fentanyl “
So what’s the problem ? Also also “The Risk of Misuse and Diversion of Buprenorphine for Opioid Use Disorder Appears to Be Low in Medicare Part D”
Some doctors advocate over the counter buprenorphine. I’m not there yet, but I sure see good reason to reduce restrictions on suboxone. For one thing, it should definitely be offered to opioid addicts in prisons and jails. Detoxification (withdrawal) does not end dependency. People generally relapse if forced to endure withdrawal. A key role of medically assisted treatment is blocking opioid receptors so the patient can’t get high — they do not work just by preventing symptoms of abstinence.
a better version of this post (also written by an MD) is here. The claim is that suboxone should be made available to all people who seek it and that it helps even if not combined with counseling.
The title of the post also refers to buprenorphine+Naltrexone. Naltrexone is absorbed unlike Naloxone, so it reduces the effect of buprenorphine. I still advocate a slow shift from Buprenorphine (with naloxone) to Naltrexone.
These are very fine posts, however I wonder how the work done here relates to the work of Deaton-Case on what have been called deaths of despair, and also how could this American crisis be compared with the situation in another country, say, Spain or the UK? Comparison with another country could be helpful.
https://www.pnas.org/doi/10.1073/pnas.2024777118
March 8, 2021
Life expectancy in adulthood is falling for those without a BA degree, but as educational gaps have widened, racial gaps have narrowed
By Anne Case and Angus Deaton
Significance
Without a 4-y college diploma, it is increasingly difficult to build a meaningful and successful life in the United States. We explore what the BA divide has done to longevity, focusing on a measure of expected years lived between ages 25 and 75. In the richest large country in the world, with frontier medical technology, expected years lived between 25 and 75 declined for most of a decade for men and women without a 4-y degree, even prior to the arrival of COVID-19. For those with and without a BA, racial divides narrowed by 70% between 1990 and 2018, while educational divides more than doubled for both Black and White people.
Expected years lived between 25 and 75? Isn’t that always 50?
We explore what the BA divide has done to longevity, focusing on a measure of expected years lived between ages 25 and 75….
[ This means beginning at 25 or 30 or 35… how many years can a person be expected to live.
Deaton is a Nobel Prize winner and with Case was long a Princeton professor. They are never careless in their writing. ]
Thanks. In my prior work we developed very similar models to underwrite long-term maintenance agreements, but had to keep very large reserves until the modeled population reached 40% completion. For example we might could life expectancy at end 2022 for those born in 1997 (25 year-olds) but we’d be very cautious using the model until 40% of 1997 births had died. Not sure when that might happen but guessing around 70 years-old.
https://www.pnas.org/doi/10.1073/pnas.2024777118
March 8, 2021
Life expectancy in adulthood is falling for those without a BA degree, but as educational gaps have widened, racial gaps have narrowed
By Anne Case and Angus Deaton
Abstract
A 4-y college degree is increasingly the key to good jobs and, ultimately, to good lives in an ever-more meritocratic and unequal society. The bachelor’s degree (BA) is increasingly dividing Americans; the one-third with a BA or more live longer and more prosperous lives, while the two-thirds without face rising mortality and declining prospects. We construct a time series, from 1990 to 2018, of a summary of each year’s mortality rates and expected years lived from 25 to 75 at the fixed mortality rates of that year. Our measure excludes those over 75 who have done relatively well over the last three decades and focuses on the years when deaths rose rapidly through drug overdoses, suicides, and alcoholic liver disease and when the decline in mortality from cardiovascular disease slowed and reversed. The BA/no-BA gap in our measure widened steadily from 1990 to 2018. Beyond 2010, as those with a BA continued to see increases in our period measure of expected life, those without saw declines. This is true for the population as a whole, for men and for women, and for Black and White people. In contrast to growing education gaps, gaps between Black and White people diminished but did not vanish. By 2018, intraracial college divides were larger than interracial divides conditional on college; by our measure, those with a college diploma are more alike one another irrespective of race than they are like those of the same race who do not have a BA.
https://fred.stlouisfed.org/graph/?g=15a9v
January 15, 2018
Life Expectancy at Birth for United States, United Kingdom, France, Germany and Italy, 2017-2021
https://fred.stlouisfed.org/graph/?g=16fHc
January 15, 2018
Life Expectancy at Birth for United States, United Kingdom and Ireland, 2017-2021
Also, a question that puzzles me: is there any relation that you may know of between this US crisis and the sharp rise in disability?
https://fred.stlouisfed.org/graph/?g=17Gay
January 4, 2020
Labor Force and Population with a disability, * 2010-2023
* Age 16 and over
https://fred.stlouisfed.org/graph/?g=17ENT
January 4, 2020
Labor Force men and women with a disability, * 2010-2023
* Age 16 to 64
(Indexed to 2010)
https://news.cgtn.com/news/2020-06-15/United-states-of-despair-RlCkSfaJvG/index.html
June 15, 2020
United states of despair
By Anne Case and Angus Deaton
Well before COVID-19 struck, there was another epidemic running rampant in the United States, killing more Americans in 2018 than the coronavirus has killed so far. What we call “deaths of despair” – deaths by suicide, alcohol-related liver disease, and drug overdose – have risen rapidly since the mid-1990s, increasing from about 65,000 per year in 1995 to 158,000 in 2018.
The increase in deaths from this other epidemic is almost entirely confined to Americans without a four-year college degree. While overall mortality rates have fallen for those with a four-year degree, they have risen for less-educated Americans. Life expectancy at birth for all Americans fell between 2014 and 2017. That was the first three-year drop in life expectancy since the Spanish flu pandemic of 1918-19; with two epidemics now raging at once, life expectancy is set to fall again.
Behind these mortality figures are equally gloomy economic data. As we document in our book, real (inflation-adjusted) wages for U.S. men without a college degree have fallen for 50 years. At the same time, college graduates’ earnings premium over those without a degree has risen to an astonishing 80 percent. With less-educated Americans becoming increasingly less likely to have jobs, the share of prime-age men in the labor force has trended downward for decades, as has the labor-force participation rate for women since 2000.
Educated Americans are pulling away from the less-educated majority not only in terms of income, but also in health outcomes. Pain, loneliness, and disability have become more common among those without a degree….