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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2 min read

Changing the Culture Within Hospitals to Make the Biggest Impact

By Mark Powell on September 10, 2019

 
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2 min read

Joining Forces to Offer Hope

By Mark Powell on September 10, 2019

 

Like many states, Oregon is a patchwork quilt of big cities, small towns, and wide rural expanses. And like many other states, its rural regions haven’t been spared from the opioid crisis.

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2 min read

Nurturing Prenatal Care

By Mark Powell on September 10, 2019

 

For a long time, women in Oregon who were both pregnant and fighting addiction were caught in a Catch-22. Addiction providers didn’t want to work with pregnant women because of potential complications. And maternity care providers didn’t want to work with women suffering from addiction because of lack of understanding and expertise in that area.

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6 min read

Now What? THC Exposure and the Adolescent Brain

By Mark Gold, MD on August 29, 2019

As more states move to decriminalize or legalize marijuana and THC-related products, researching potential harms associated with cannabis use is an even more important field of study. In certain cases, such as marijuana-related medications, there is sound evidence. Usually, the manufacturer of a drug has to do clinical trials, called FDA trials, to demonstrate dose, safety, and efficacy for a particular problem or illness. The FDA did approve the first drug comprised of an active ingredient derived from marijuana to treat rare, severe forms of epilepsy. This was a well-conceived and logical trial and process. It resulted in the approval of Epidiolex (cannabidiol, or CBD) oral solution for the treatment of seizures associated with two rare and severe forms of epilepsy, Lennox-Gastaut syndrome and Dravet syndrome, in patients two years of age and older. This was the first FDA-approved drug that contains a purified drug substance derived from marijuana. It was also the first FDA approval of a drug for the treatment of patients with Dravet syndrome. Notably, however, the FDA did not approve a crude plant or marijuana, but CBD. CBD does not cause intoxication or euphoria, the “high” that comes from marijuana’s tetrahydrocannabinol (THC). In this case, we know that the medication is safe, we know its formulation and composition, and we know the dose. We also know that before this treatment, there were no good alternatives.

According to pediatricians and research scientists, there’s no scientific evidence supporting the acceptability of adolescent marijuana use, and products sold in dispensaries pose considerable risks to children and teens.1 The situation with cannabis, vaping THC, and other preparations is considerably different from that of an FDA-approved medication. In these cases, sadly, we are doing the research after the fact. We know that laws are meant to prevent children from using and smoking marijuana, but the public appears confused about safety warnings when children and adolescents seem like they are safely given cannabis for seizures. Recent data shows that use is increasing among young people. A SAMHSA report found that marijuana is teens’ most widely used illicit drug.2 Frequent marijuana use, in both youth (aged 12-17 years) and young adults, appears to be associated with risk for opioid use, heavy alcohol use, and major depressive episodes. Youth have access to the legal cannabis and related product markets, as well as the thriving illicit marketplace for drugs. Health problems linked to vaping may be in the headlines, as many of those with reported lung damage have vaped THC, but it is not the only problem facing teen users.3 

What does the latest research tell us about the effects of cannabis on the adolescent brain, and do we know enough to make recommendations? 

Science has not shown that cannabis is performance-enhancing like amphetamines, psychostimulants, or medications like methylphenidate given to people with learning problems. Research has clearly shown that adult cannabis use can affect a person’s memory, performance and ability to learn. Recently, Gorey et. al. conducted a systematic review of 21 human and animal studies to investigate whether age influenced the effects of cannabis on the brain, and found preliminary evidence that suggested it does. Further understanding the differences between how cannabis affects the adult brain versus the adolescent one could help us create better messaging and education for youth about how cannabis could affect them.  

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4 min read

We have vaccines for polio and the flu, how about opioid addiction?

By Mark Gold, MD on August 22, 2019

Preliminary 2018 data from the Centers for Disease Control show a slight decline in drug overdose deaths.1 In the view of many experts, increased availability and use of Naloxone, education, and also increased access to Medication for Addiction Treatments (MAT) contributed to this decline.2 However, opioid use disorders and drug overdose rates remain extremely high nationally. Moreover, decreasing overdoses from prescription misuse and heroin should not distract from rising importation, misuse, and overdoses due to fentanyl, methamphetamine, and cocaine.3 With limited treatment options available for these substance use disorders, researchers are working to create novel approaches, using all technologies available, to prevent, treat, and improve the lives of patients and families. In a number of studies and trials, Tom Kosten and his colleagues at Baylor have looked at cocaine, methamphetamine, opioid and even fentanyl vaccines, showing promising results in reducing overdose, misuse, and treating substance use disorders.4 

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