New challenges in the opioid epidemic

Updated: Sep 10

by Dr. Mark Gold


Here’s how Harvard University and McLean Hospital experts explain some of the challenges of opioid use disorder (OUD):


“When we counsel our patients with substance use disorders to reduce or stop using substances, it is essential that we bear in mind exactly what we are asking of them: to exert an athletic level of discipline and sustained determination, without much training or experience, in behavioral self-control that is fully counter to their neurobiological drives, and all too often supported only by fear incentives.”


CDC data shows that heroin deaths dipped in 2018, and deaths from prescription opioids decreased by 15 percent, helping to achieve the first decline in U.S. drug deaths in decades. But the CDC also reports rising fentanyl deaths, especially in the west. OUD isn’t just a problem because of fatal overdoses—there are still thousands of patients in need of intervention and treatment. There are few alternatives for people with chronic pain who need relief they can only reliably find at present in a form that may be addictive.


New OUD research is published all the time to address these gaps in knowledge, highlight new challenges, and develop best practices. A good portion of these studies also provide important information about misunderstood or underrated aspects of the condition. Staying up to date with OUD research helps officials, practitioners, families, patients, and communities recognize the most salient features of the complicated nature of this health condition and the shifting opioid epidemic. The recent expert opinion piece, which considers length of buprenorphine treatment in the context of broader recovery needs and interests, is a good place to start.


What do experts say about length of buprenorphine treatment and patient health?


This editorial comments on a study that tracked 9,000 adults receiving Medicaid between 2013 and 2017.1Patients filled prescriptions for buprenorphine for at least 6 months before stopping, when the study tracked their overdoses, other prescriptions, hospitalizations, and emergency department visits. To measure health outcomes based on length of buprenorphine treatment, this study broke up patients into four groups according to treatment length: 6-9 months, 9-12 months, 12-15 months, and 15-18 months. All groups had a similar nonfatal overdose rate, around 6 percent, and went to the emergency department at a generally high rate, above 40 percent. Compared to patients who continued treatment for 6-9 months, patients who had continued treatment for 15-18 months received fewer prescriptions, and were hospitalized and in the emergency room less often.


The editorial notes that the study aligns with United Kingdom research finding that OUD patients continuing buprenorphine for 2 years fared better relative to shorter treatment times and asks, “Would 3 years, or even more, be better than 2?” Its answer is that it’s unclear but not the only factor—patient outcomes will also vary according to physical health and wellness, identity, family, and other social and personal variables. Positive motivation shapes recovery, this editorial argues, with strong relationships, work, spirituality, finances, and sense of meaning in life all influencing a patient’s course. This editorial argues that studies show both the importance of continuing treatment for OUD and the importance of paying attention to patients’ overall needs.


What do other recent studies say about OUD?


A recent study on OUD’s course in the brain finds that increased amounts of opioid use change the brain’s emotional plasticity, creating alterations that last into abstinence and help lead to continued desire for opioids.2 A recent review also finds that studies of mice in withdrawal show negative behavioral responses and worse emotional states similar to those of human opioid withdrawal.3 Another study calls for the creation of targeted treatments to curb OUD by fighting chronic pain and comorbidities like depression,4 and another for the combination of phenotyping, neurobiological analysis, biology, and genetics to create medications “that will lead to effective replacements for opioids”.5


These findings are also important for youths with OUD, an easily overlooked but vulnerable population. One new study found that less than a third of youths had access to treatment after a nonfatal opioid overdose—and that only 1 out of 54 had access to pharmacotherapy.6 This study tracked nonfatal overdoses among almost 3,800 youths identified in the Medicaid claims database from 2009-2015. The group had an overdose rate of 44.1 per 100,000, and almost 70 percent of a subgroup received no treatment 30 days after their overdoses. 29 percent had access to behavioral health services, and only about 2 percent received pharmacotherapy. This study’s authors conclude, “Interventions are urgently needed to link youths to treatment after overdose, with priority placed on improving access to pharmacotherapy.”


This level of urgency in analysis of youth and OUD is evident in other studies, too. A January study looked at the CDC’s 2017 Youth Risk Behavior Surveillance Survey of high school students to gauge how many adolescents misusing opioids engaged in other risky behaviors.7 It found that “Those who misused prescription opioids were significantly more likely to have engaged in all 22 risky behaviors compared with other adolescents.” These other risky behaviors include not wearing a seatbelt, having ridden with an intoxicated driver and driven under the influence, having sex before age 13, refraining from using a condom, carrying weapons, attempting suicide, and trying other substances. Those working with adolescents should consider screening for these other factors and paying careful attention to the range of adolescents’ experiences.


What’s next for OUD?


Opioids have played a significant role in what are sometimes called U.S. “deaths of despair”, a term coined by the economists Anne Case and Angus Deaton to refer to rising fatalities from drugs, suicides, and alcohol among Americans without college degrees. This continues to be an important story, but the journalist Charles Lehman suggests distinguishing between the demographic group and these 3 categories of deaths—and between different drugs. If you do, it’s clear that America has a polysubstance crisis, and that fentanyl leads the pack. Fentanyl is inexpensive, can still displace much of the U.S. heroin market, and isn’t likely to inspire a “consumer backlash” because few using the product actually seek it out. It’s created a crisis that’s still getting worse. And its prominence means that OUD is likely to be with us as a serious disease affecting millions for some time.


Patients with OUD often have continuously high risks of overdose. The best outcomes appear to be related to treatment duration of about 2 years. But rates of poorer health outcomes may remain high. This is why recent OUD studies are important: they help to clarify the scope of the crisis, like the range of treatment options patients need, developments in brain science and the potential for new medications, and emerging trends like risky youth use patterns. Headlines purporting to identify good news in drug death figures don’t always get below top-level data to spot alarmingly dangerous trends like surging fentanyl deaths. The OUD crisis, and its patients, aren’t going away.


References:

Connery, H.S., Weiss, R.D. (2020). Discontinuing Buprenorphine Treatment of Opioid Use Disorder: What Do We (Not) Know? American Journal of Psychiatry, 177(2), 104-106. doi: 10.1176/appi.ajp.2019.19121245


Koob, G.F. (2020). Neurobiology of Opioid Addiction: Opponent Process, Hyperkatifeia, and Negative Reinforcement. Biological Psychiatry, 87(1),44-53. doi: 10.1016/j.biopsych.2019.05.023


Welsch, L., Bailly, J., Darcq, E., Kieffer, B.L. (2020). The Negative Affect of Protracted Opioid Abstinence: Progress and Perspectives From Rodent Models. Biological Psychiatry, 87(1), 54-63. doi: 10.1016/j.biopsych.2019.07.027


Serafini, R.A., Pryce, K.D., Zachariou, V. (2020). The Mesolimbic Dopamine System in Chronic Pain and Associated Affective Comorbidities. Biological Psychiatry, 87(1), 64-73. doi: 10.1016/j.biopsych.2019.10.018


Woolf, C.J. (2020). Capturing Novel Non-opioid Pain Targets. Biological Psychiatry, 87(1), 74-81. doi: 10.1016/j.biopsych.2019.06.017


Alinsky, R.H., et al. (2020). Receipt of Addiction Treatment After Opioid Overdose Among Medicaid-Enrolled Adolescents and Young Adults. JAMA Pediatrics, [online ahead of print]. doi: 10.1001/jamapediatrics.2019.5183


Bhatia, D., Mikulich-Gilbertson, S.K., Sakai, J.T. (2020). Prescription Opioid Misuse and Risky Adolescent Behavior. Pediatrics, 145(2), e20192470. doi: https://doi.org/10.1542/peds.2019-2470


Citation:

1. Connery, H.S., Weiss, R.D. (2020). Discontinuing Buprenorphine Treatment of Opioid Use Disorder: What Do We (Not) Know? American Journal of Psychiatry, 177(2), 104-106. doi: 10.1176/appi.ajp.2019.19121245

Dr. Mark S. Gold is a teacher of the year, translational researcher, author, mentor and inventor best known for his work on the brain systems underlying the effects of opiate drugs, cocaine and food.

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