Fentanyl, Methadone, Buprenorphine and Naltrexone

One of these things is not like the others. Fentanyl is killing about 70,000 Americans a year. The others are known to be useful in treating opioid dependency yet (in 2014 sorry will Google more) only half of private opioid use disorder treatment programs offered pharmaceuticals and less tha one third of patients actually received the drugs “The proportion of opioid treatment admissions with treatment plans that included receiving medications fell from 35 percent in 2002 to 28 percent in 2012.9” This is crazy.

There is one claim in the linked article which is also not like the others “Medications should be combined with behavioral counseling for a “whole patient” approach, known as Medication Assisted Treatment (MAT).” that is a complete quote. There is no citation of a reference supporting the claim. I have read that claim many times recently. I have not seen any link to any supporting evidence (I will assume for the sake of argument that there is evidence somewhere that a “‘whole patient'” approach is more effective than a just give them pills (or gum) approach, but I haven’t run across any links to it.

A link to (slightly) more recent data “However, overall use of medications in the USA remains low. In 2017, only 16.3% of specialty treatment programs offered any single medication for alcohol use disorder treatment and 35.5% offered any single medication for opioid use disorder treatment. ”

Importantly “A recent report by the National Academies of Sciences, Engineering, and Medicine concluded that “a lack of availability or utilization of behavioral interventions is not a sufficient justification to withhold medications to treat opioid use disorder” [15]. This statement reflects mounting support for the use of medications in the absence of psychosocial therapy.” [National Academies of Sciences E, and Medicine. Medications for opioid use disorder save lives. Washington, DC; 2019.] The National Acadamies of Sciences, Engineering, and Medicine are not fringe or obscure, yet I have read again and again that “Medications should be combined with behavioral counseling” without either a reference to this report or an attempt to refute its claims.

In particular, I have a strong opinion about Naltrexone, which is an opioid antagonist — no dose causes euphoria, it can not be abused. It is currently a prescription medicine in the USA. Why ? What if someone trying to kick an opioid habit wants to precommit to no high today without dealing with doctors ? Why not. Frankly the side effects of which patients complain sound a lot like complaints most people make and also like symptoms of opioid withdrawal. I think Naltrexone should be available over the counter. Why not (costs and benefit analysis please not just costs and especially not hypothetical costs).

I also ask why ” geographic disparities in access to buprenorphine remain”ed at least in 2017 ? Why isn’t Biden campaigning (more strenuously and loudly) for universal access to effective opioid addiction treatment ?

Googling I just learned there are last 6 months slow release Buprenorphine implants FDA approved over 7 years ago. Why was I ignorant about that ? The courtesy of not typing “because you are dumb and lazy” is requested.

update: For a long time, I have wondered why pharmaceutical based treatment of opioid dependency always relies on one pharmaceutical. It seems to me that the reasonable strategy involves moving from opioid to opioid antagonist. That is start with methadone (an opioid which definitely satisfies cravings but can be diverted and abused). Second week 80% methadone 20% buprenorphine (a weak opioid agonist which relieves cravings but mainly bockes opioid receptors) then 60% – 40% etc. until 100% buprinorphine and no methadone. At this point, there is basically zero risk of diversion and treatment can continue from a doctor’s office not a clinic.

I would go on to 90% buprenorphine 10% naltrexone (and antagonist which blocks the receptors) then in a week 80% 20%. In 10 weeks pure naltrexone which, as argued above, can be sold over the counter and used without supervision. I see no disadvantage of shuch a gradual shift to less opioid agonist activity.

update: Waldman[n]s think alike. This post on opioids by Paul Waldman is much better than my post on the topic. In particular “at the end of last year, Biden signed a bipartisan bill allowing all doctors to prescribe the treatment drug buprenorphine, eliminating a special certification to do so. All the experts I spoke with cited that as a significant accomplishment, even if most Americans never heard about it.” is important (and I was one of the Americans who hadn’t heard about it).

This ends the maybe useful part of the post. Below I speculate about why drug treatment of drug addiction isn’t more available.

  1. The title of this section is a possible answer. It is counter-intuitive to suggest that the solution to people trying to solve their problems with pills (or injections) is more pills.
  2. NIMBY no one wants a methadone clinic in their neighborhood. This is one reason why I support over the counter Naltrexone. Also doctor’s office buprenorphine (people don’t have to be watched while they take it — it is too weak to please druggies and very little is diverted see some link above).
  3. No pain no gain. There is clearly a sinners must repent and do penance logic. Easy solutions are viewed with suspicion.
  4. treating the symptoms not the disease — drug dependency doesn’t fall out of the sky — there is a prior sociological or psychological problem. This does not mean that pharmaceutical treatment doesn’t work (facts don’t care about your intuitions).
  5. letting the best be the enemy of the good. I have conceded (for the sake of argument) that whole patient care is better, but it is also not available, nor will it be any time soon.
  6. Compromise — advocates of drugs for druggies (especially back when that meant methadone only) insist that they aren’t saying drugs for drugs are a simple cure all but rather should be part of a blah blah blah.