Medication Assisted Treatment
Narcan brings people back from the brink of death, but what is there to help them get their life back on track - Connor Narciso
Up until a few years ago, only medical professionals were familiar with naloxone, a medication used to revive opioid overdose victims. Now librarians, school nurses, baristas, parents - anyone who might need to save a life – can carry naloxone and administer it in emergencies as a nasal spray sold as Narcan.
Now comes a provocative new study by economists Jennifer Doleac of the University of Virginia and Anita Mukherjee of the University of Wisconsin. Their paper, The Moral Hazard of Lifesaving Innovations: Naloxone Access, Opioid Abuse, and Crime, concludes that naloxone, which works by dislodging opioid molecules from the brain to jump-start breathing, may not increase the number of lives saved after all.
Doleac and Mukherjee’s argument is that by reducing the risk that abusers will die, the antidote makes opioids more appealing. And, “by increasing the number of opioid abusers who need to fund their drug purchases, naloxone…may also increase theft,” wrote the researchers.
The research presents a classic case of moral hazard: insuring against calamity encourages the behavior that produces calamity. If you’re insured against losing a diamond ring, you are more apt to leave it in a drawer than in a safe.
The authors compared crime and mortality rates in states with Naloxone Access Laws before and after those laws were passed. Such laws institute standing orders that allow pharmacists to dispense naloxone to a layperson without needing a prescription. Data collected between 2010 and 2015 were analyzed.
I, too, have wondered about the impact of naloxone on user attitudes and asked some of the patients in my methadone clinic whether having naloxone at home ever influenced their drug-taking behavior. A few told me that, yes, they probably took extra risks just because they knew that someone could rescue them if they “went out.”
At the level of the individual, life-saving methods like naloxone, especially those that are highly effective, absolutely must be used. For a doctor, this imperative could not be stronger.
The paper by Doleac and Mukherjee, which studied a natural experiment comprising millions of people, not a handful of patients, drew intense criticism.
Reactions to the study ranged from puerile (how dare researchers even ask about moral hazard!) to constructive. Three scholars in the latter camp, for example, noted that a key assumption of the study, namely that naloxone access laws had a large impact on actual naloxone use, has not actually been observed on the ground.
The debate continues but the researchers and their critics agree on two things. First, that no one who overdoses should be left to die. Second, that expanding drug treatment is essential. Indeed, Doleac and Mukherjee reported an impact of access laws appears to be related to treatment availability: the more treatment, the fewer deaths and crime.
This is critical because when naloxone saves someone, it shouldn’t be so that she can die another day. Sadly, that can happen. In fact, a recent study found that one in ten Massachusetts residents who were revived by naloxone died within a year. Police and emergency personnel attest to the frequency with which revived individuals, now in a highly agitated state of induced withdrawal from opioids, walk off within minutes of being revived to use or purchase more drugs.
For people who do want treatment, however, the good news is that three FDA-approved medications exist to treat opioid addiction. Together, the three are often termed “medication-assisted treatment,” or MAT.
The classic treatment is methadone, first introduced as a maintenance therapy in the 1960s. A newer medication approved by the FDA in 2002 for the treatment of opioid addiction is buprenorphine, or "bupe." It comes, most popularly, as a strip that dissolves under the tongue, sold as Suboxone. Like methadone, bupe is an opioid. Thus, it can prevent withdrawal, blunt cravings, and produce euphoria. Unlike methadone, however, bupe's chemical structure makes it much less dangerous if taken in excess, thereby prompting Congress to enact a law which allows physicians to prescribe it from their offices. Methadone can only be dispensed in a special clinic.
In addition to methadone or buprenorphine, which have abuse potential of their own, there is extended-release naltrexone. Administered as a monthly injection, naltrexone, sold as Vivitrol, is an opioid blocker. A person who is "blocked" normally experiences no effect upon taking an opioid drug.
Naltrexone is not an opioid, but it has a drawback: It cannot be administered until opioid-users have gone through a three-to-five day detoxification to purge all remaining opioid from their bodies. Many opioid addicts cannot tolerate “going cold turkey” for a week and insurance, if one has it, does not reliably cover an inpatient-based detox. For this reason – and because naltrexone has no intoxicant properties and therefore won’t be diverted for profit – naltrexone has become the drug of choice to dispense to already-detoxed jail and prison inmates in preparation for release.
Once stabilized on these medications, patients can begin the lengthy process of rehabilitation.
This is how it is supposed to work. But two major problems cloud the picture. One is the poor state of the nation’s treatment infrastructure. A recent study found that only 23% of U.S. drug-treatment facilities provide two or more medications. In its report issued in November, the President’s Commission on Combating Drug Addiction and the Opioid Crisis called for tearing down barriers that prevent the treatments from getting to the people who need them, but so far those barriers remain.
The other is retention in care. After all, a treatment clinic on every block won’t matter unless addicted individuals are motivated to participate. A study published in The Lancet in November, for example, found that buprenorphine and naltrexone were equally effective once both were initiated, but about half of those who took the medications relapsed within 24 weeks.
This attrition rate reflects scores of published reports of premature departure rates of 40 to 60 percent within six months of enrollment. A year or two is the accepted minimum of sustained treatment; drop out typically means resumption of drug use. I have written here about ways to enhance retention in care.
If it turns out that there is indeed a moral hazard associated with naloxone, then our job is to mitigate that unintended consequence with enhanced access to treatment. For many opioid users, the efforts to get them into treatment and engage them in recovery begin with resuscitation from overdose. Naloxone brings drug abusers back to life. Methadone, buprenorphine, and naltrexone can help keep them there.
Source: Sally Satel, Naloxone, Yes, But 3 Other Drugs Are Essential to Fight the Opioid Epidemic, Forbes, March 19, 2018.