Addiction Policy Forum Blog

9 min read

The truth about MAT? Patients know the virtue

By Mark Gold, MD on October 3, 2019

47,600 people died from drug overdoses involving opioids in 2017. Between 2012 and 2018, the number of fentanyl-induced fatal overdoses rose dramatically, accounting for a majority of overdose deaths. While preliminary data from the Centers for Disease Control shows a marginal decline in fatal overdoses in 2018, from 70,237 to 68,557, it also reveals that fentanyl is still the primary cause of fatal overdoses.1 Naloxone is a non-opioid wonder drug that can reverse an opioid overdose. It is short-acting, and by temporarily reversing the effects of opioids, it gives a person with an opioid use disorder (OUD) a second chance—an opportunity to receive treatment. As a result of campaigns by, among others, the Surgeon General2 and the CDC to improve naloxone access, retail pharmacies increased naloxone dispensing from 2012 to 2018. Despite the increase in dispensation by pharmacies, only one naloxone prescription was dispensed for every 69 high-dose opioid prescriptions in 2018.3 In the old days, I remember patients saying that they felt stigmatized at the pharmacy when they heard, "Mr. Jones, your Elavil is ready." Stigma kept many depressed patients from filling prescriptions. But in this case, is the challenge both stigma and the lack of pharmacist or health care provider education?4 It is tough to pinpoint a cause explaining this data. 

The CDC and Surgeon General encourage us to improve naloxone access at the local level, including through prescribing and pharmacy dispensing. Widespread distribution of naloxone is an essential component of the public health response to the opioid overdose epidemic. Unfortunately, the lowest rates of naloxone dispensing are in the areas with the highest opioid overdose rates. We are in the third phase of the opioid epidemic, with pain clinics’ overprescribing practices overtaken first by heroin and, more recently, by fentanyl. Individuals who overdose often overdose again, and many patients treated in addiction programs or health providers' offices through MAT often relapse.

For the treatment community, adverse outcomes and continued overdose deaths are, naturally, extremely upsetting. OUD treatment program employees frequently complain of burnout. High turnover in many programs is a major problem. Some are frustrated by recidivism rates, others because some patients are not offered MAT. Some patients cease their MAT course, and others drop out of treatment altogether. Yet experts have consistently agreed that while MAT, due to a lack of options, has not helped us combat cocaine or methamphetamine use disorders, it can be enormously helpful in managing OUD. A recent review, written by James Bell and John Strang, looks at the overall evidence on MAT and compares the relative benefits of different medications, helping to shed light on this critical public health issue. It is important to keep in mind, however, how contentiously and frequently some of our evidence is debated. We lack, for example, prospective, long-term, oncology-like, 5-year studies on the subject. MAT is debated—and so are standards measuring patient "outcomes." For a physician with an OUD, the relevant outcome standards may include a return to practice, 5-year sobriety, urine testing, and fitness for duty. In other cases, outcome standards may include coming to a treatment program, or following an MAT course, or simply not overdosing or dying. 

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7 min read

What is TMS and can it help treat withdrawal, addiction, and patients with SUDs like it can treat depression and OCD?

By Mark Gold, MD on September 19, 2019

In April, The Atlantic published a piece about a young woman who became a viral internet sensation after she was photographed wearing a futuristic-looking hat or device on her head.1 Some online commentators dubbed the large, grey headwear, connected by a strap under the chin, “the depression helmet.” What the commentators did not understand is that such devices are part of a safe, effective, FDA-approved treatment for depression: transcranial magnetic stimulation, or TMS. At the University of Florida, in 2008, I was part of a team that purchased one of the first TMS machines sold after FDA approval. We bought other machines and did TMS research as well. Since that time, the technique has been used successfully to treat depression around the world. It was also approved in 2013 for the treatment of pain associated with certain migraine headaches, and more recently approved for the treatment of Obsessive-Compulsive Disease.2

At least 100 randomized clinical trials have been completed in an attempt to find a MAT which might treat cocaine use disorder, employing over 50 chemical compound medications. With very little progress made from early work3, none have been shown to be particularly useful4, until the current day and TMS. Treatment must reverse more than acute or even chronic dopamine neuron effects of cocaine. The TMS research group at the National Institute of Drug Abuse (NIDA) in Baltimore works on TMS research, dopamine plasticity, cocaine and SUD-related dopamine changes. TMS offers us a chance to intervene against cocaine and other substance’s ability to change the firing rates and key brain circuits that ultimately reduce dopamine release. The TMS research group is working to define how SUDs change the brain, intrinsic and synaptic plasticity control dopamine neurons, and what might be done to return the brain to pre-drug functionality.5

NIDA TMS researchers were featured in a cover story on the science of addiction in National Geographic.6 This article describes how a psychiatrist in Italy, who has treated addiction for 30 years,  became interested in TMS and began using it for treatment. It also details the successful use of traditional TMS treatment on a chronic relapsing patient, treated as if he had a naturally occurring depression. The psychiatrist, patient, and NIDA researchers are all interviewed for the story. TMS is not shock therapy; it delivers electromagnetic pulses to the brain in dopamine rich areas, resulting in painless, rapid magnetic pulses delivered through a pad or cap or hat. It is called non-invasive, and clearly has the ability to use  magnetic stimulation to drive the brain’s circuitry with electric currents. TMS can increase and decrease cortical excitability, through high and low frequency wave generation.  Scientists are very excited about this as TMS may help rebuild neural connections, or possibly regenerate dopamine systems damaged by substance use. The psychiatrist featured in the National Geographic article, Luigi Gallimberti, MD, has subsequently used TMS to treat other addictions. 

Medication assisted therapies are approved and used for detoxification, maintenance, and relapse prevention. Unfortunately, these do not address many of the changes produced by cocaine and other drugs. Even patients following these treatment plans and taking medications often feel a lack of energy, diminished pleasure, and declining enthusiasm, and drop out of treatment. TMS might not help people to stop using drugs, but it could be beneficial in helping with addiction and post-addiction related depression and anhedonia.7 TMS researchers have become part of a promising frontier for combating craving, addiction, relapse, and co-occurring depression. Greeting with laughter images of TMS devices, caps, and hats is a perfectly unhelpful reaction in the middle of a major opioid crisis.

FDA approval for treating depression through TMS piqued interest in applying the technique to substance use disorders, since depression is often a major part of SUDs, and a cause of relapses and overdoses, as a recent consensus review on the current state of non-invasive brain stimulation science pointed out. Neuroscience research has helped establish connections between substance-using behavior and particular neural circuits, which prompted additional interest in using TMS and related techniques to treat substance use disorders. TMS is no longer an experiment. With time, SUD researchers have compiled more studies on non-invasive brain stimulation, symptoms, and outcomes, leading to new reviews on relative effectiveness and future development prospects.


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1 min read

#RecoveryMonth: Recovery Happens — a Mother’s Story

By Jill Ditlevsen on September 18, 2019

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2 min read

A New Look At An Old Problem

By Mark Powell on August 6, 2019

 

Opioid misuse is deeply pervasive, even in an all-American place like Marshalltown, Iowa. It’s estimated 1 in 6 children live in a home with active addiction. “As a family doctor in the community for 20 years, I’m burying someone every week,” says Dr. Tim Swinton. “I’m seeing people struggle throughout their lives and then have kids who also struggle. And they use drugs to deal with the stress of it all.”

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4 min read

What Role Should Psychiatrists Play in Responding to the Opioid Epidemic?

By Mark Gold, MD on March 21, 2019

As America continues to deal with an opioid overdose epidemic of staggering proportions, public health initiatives are faced with the needs of the more than 1.7 million people who are suffering from opioid use disorder (OUD) as of 2017.1 This crisis is exacerbated by the shortage of health care practitioners trained and able to use FDA approved medication, like buprenorphine, to treat patients with an OUD. In a nation with a population exceeding 320 million, there are only 1100 psychiatrists specializing in addiction—the need for providers who are equipped and able to treat OUD is greater than ever. In a recent paper from the Yale School of Medicine Srinivas B. Muvvala, MD, MPH, Ellen Lockard Edens, MD, MPE, and Ismene L. Petrakis, MD, call upon psychiatrists and mental health professionals to play a more active role in addressing the current opioid crisis.

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