The History of Medication-Assisted Treatment for Opioid Use

The United States is currently in an opioid crisis. This crisis was caused by a combination of many factors. One of the main sources of this epidemic was the misuse, overprescription, and abuse of opioid-based medications in the medical industry. There were also countless illegal organizations whose production and distribution of opioids exacerbated the epidemic’s severity several times throughout the history of the United States.

This same complex history also details many well-intended efforts to alleviate pain and serve the public that were unfortunately plagued by misunderstandings and misinformation.

Putting all these pieces together tells a story of assumptions:

The assumption that opioids were a safe and an effective continuous medication for chronic pain.

The assumption that without the use of opioids better alternatives would naturally be found for those with chronic pain.

The assumption that those who were suffering from Opioid Use Disorder (OUD) could cure their addiction themselves or with minimal assistance.

With the state of the current opioid epidemic, these assumptions have begun to give way to greater medical scrutiny and the creation of new laws to limit opioid dose prescriptions. These steps forward have been largely due to peer-reviewed studies into the dependence on opioids after initial prescription, allowing us to better understand just how addictive these drugs can really be.

The prevention of overdose death and the development of OUD treatment options have become the focus in the last several years, as therapy and healing have begun to open doors that were closed when the primary deterrent available was legislation.

The potential to save lives has become the priority as opioid death rates unfortunately continue to rise in the United States. The goal of opioid treatment then, is to return people to productive functioning in their family, workplace, and community and mitigate the factors that lead to unnecessary deaths.

The history of the opioid use and how its progression has led us to this point is pivotal to understanding our options moving forward. Prior to the 1800’s, pain was not an identified symptom in the way that is now, rather pain was seen as simply a consequence of aging, rather than a sign that something was wrong with the patient’s physical health. Because of this, Prior to the 1800s, opium was commonly used for various ailments. Opium derivatives, such as laudanum, were often marketed and dispensed as remedies for a range of pain-based ailments.

As this early era of prescription medication moved along, physicians were thankfully slowly influenced to avoid opioids. Due largely to the rising presence of heroin availability on city streets, the Harrison Narcotic control Act of 1914 required those selling, distributing, or manufacturing opioids to register with the Bureau of Internal Revenue under the Treasury Department. The Harrison Narcotic Control Act was primarily aimed to regulate and tax the production, importation, and distribution of opiates and coca products. While not directly aimed at “combating rampant drug use”, it undeniably set a precedent for future drug control policies in the U.S. This national act of drug regulation was the first of its kind in the United States, and set the stage for what would be the nation’s common tactic for combating rampant drug-use.

This was also not the end of the opioid issue, as several more opioid crises’ swept through America as the decades passed. From 1999 to 2008 for example, there unfortunately was an almost fourfold spike in opioid overdose deaths. This statistic did not go unnoticed thankfully, and did lead to another wave of drug reform.

As the opioid epidemic continued to rage through the United States, the government and many citizen-focused groups began to acknowledge the pharmaceutical companies’ significant contributions to the continuing problem of opioid addiction. In 2007, Pharmaceutical enterprise Purdue Pharma pleaded guilty to federal charges. The allegations were focused on Purdue Pharma and their misrepresentation of OxyContin, which led to much of the healthcare industry to believe that opioids were a better treatment for long-term chronic pain than they actually were.

Purdue eventually paid over $630 million for the Justice Department’s investigations, and over $19 million as a settlement to 26 states and Washington D.C.

As medical reforms continued, the epidemic still did not abate due to legislation or legal consequence. A decade later in 2016 it was estimated that 116 people died from an opioid overdose every day. In total, 42,000 people in the United States died from opioid-related overdoses in 2016, while it was estimated that over 1 million Americans suffered from an opioid disorder like OUD.

On October 16th, 2017, the U.S. Department of Health and Human Services and the U.S. Government officially declared the opioid epidemic a public health emergency. This was a moment for not only widespread medical prescription reform, but also a stepping stone in the progression of opioid addiction treatment.

While the prior history has made the business of opioid treatment complicated at times, preventing deaths from overdose and discovering effective long-term treatment options have become the first steps to treating the ongoing epidemic. Much of this battle has focused on treating OUD specifically, as its set of symptoms and potential treatments have proven quite effective in recent years.

Opioid Use Disorder is a chronic relapsing disorder. This means that OUD is, “characterized by a problematic pattern of opioid use and preoccupation with obtaining and taking opioids, as well as using more than intended despite personal, medical, and psychosocial consequences.” Those who struggle with this disorder also tend to have developed a tolerance to the opioids they are addicted to, which means they will experience withdrawal symptoms when they eventually quit opioids and their treatment begins.

What treatment for opioid addiction looks like varies considerably from patient to patient. As the effects of opioids on brain receptors commonly reduces the pain individual feels, one of the first steps for recovery often consists of countering the results of that prior opioid addiction. This also means that any therapy or treatment has to take every patient’s unique situation into account.

Often this is can be done with medication, but we’ll talk about that momentarily. Opioid treatment can take place in a variety of different settings, can utilize several techniques for therapy, many different forms of medication, and can last for a varying amount of time depending upon the patient’s needs or their predisposition to relapse.

The choice to involve further medication in someone’s road to recovery from a medication-based addiction is an incredibly personal choice. As it is a considerable medical decision, it is also important to discuss using such medication-assisted treatments (MAT) with your therapist and doctor first.

Choosing to avoid the use of additional medication during opioid treatment is a completely fair decision to come to, it is just important that decision is made while informed. Most OUD treatment does not utilize only behavioral therapy due to limited efficacy when administered alone.

When using medication to help treat away opioid addiction, the primary function is to support the patient’s own recovery, rather than attempt to cause recovery artificially. By balancing brain chemistry, relieving or completely preventing withdrawal symptoms, and mitigating continued cravings, the support of medication in OUD recovery has been shown to be often successful.

To be clear, the treatments developed for opioid addiction that use a combination of medication and behavioral therapy are evidence-based approaches. While the original issues of the opioid epidemic were caused by our lack of understanding and our assumptions about how pain interacted with our bodies, current treatments understand how opioids affect our brain. The medical industry is also developing methods to better protect patients from the potential damage of opioid withdrawals while setting us up for continued successful treatment.

Of the potential medication-assisted treatments available, the Food and Drug Administration (FDA) have approved methadone, buprenorphine, and naltrexone for use. Each of these medications have a different effect on our neural receptors. This means that while all three have shown different levels of effectiveness, each medication does still have its own pros and cons to its use as a treatment method for OUD.

An example of the potential complications with medication-assisted treatment can be seen with the drug naltrexone.

Naltrexone is an opiate antagonist, which means it blocks the effects of opioids from reaching the patient’s brain receptors. This drug has an advantageous affect for those trying to remove the effects of opioids from their life. In fact, a recent NIDA study showed that buprenorphine and an extended-release use of naltrexone had similar effects when used to treat Opioid Use Disorders.

The complication is that naltrexone requires the patient to be completely detoxed, meaning that treatment is far more difficult to implement for a patient who is currently using opioids, or for those who are still experiencing opioid withdrawal symptoms.

The importance of this is made clear by the difficulty of detox. In a 10-day study, 25% of patients who initially requested detoxification quickly switched to longer-term but more manageable maintenance treatment. Once detoxification was complete though, both medications have shown roughly the same level of success.

Beyond treating the addiction, different medications have also been able to be utilized in the treatment of the symptoms of opioid addiction. Lofexidine, for example, is an agonist. As opposed to an antagonist like naltrexone, an agonistis a substance that mimics the actions of a hormonal or neural response to create an effect when it binds to the receptors of the brain.

Because Opioid Use Disorders tend to include behaviors of chronic relapsing, drugs of this nature are administered alongside significant counseling and behavioral treatments. Behavioral therapy is not often offered on its own as it only represents a part of overall addiction treatment, but it does play a significant part in a patient’s success.

Medication-assisted treatments are structured in a way that eases withdrawals in an attempt to prevent relapse, and reinforces the process of addiction detoxification with the long-term goal of patient stabilization. Again, the goal of opioid treatment is to return people to productive functioning in their family, workplace, and community and mitigate the factors that lead to unnecessary deaths. That is what MATs endeavor to do.

While many achievements have been made in the realm of opioid treatment have been considerable in recent years, there is still a lot of work to do. Opioids claimed the lives of over 64,000 Americans last year.

There is a stigma against drug use in America that makes conversations about opioid addiction, its diagnosis, treatment of overdose, and chronic pharmacotherapy almost absent in most medical schools. This is why it’s important to take time and disprove persistent myths about using medication to treat opioid addiction. Regardless of its efficacy, it important to know what a treatment is, and what it is not.

Methadone and buprenorphine, for example, do not substitute one addiction for another. The dose that is administered during treatment of these medications is not enough to get a patient, “high”. These medications are utilized to reduce opioid cravings and to treat the possible injuries of opioid withdrawals. They also can be used to restore balance to brain activity, and allow a patient’s mind to heal slowly while behavioral therapy is utilized as the main tool to recovery.

The use of additional medication to help recover from an existing medication abuse is a very personal choice. Regardless of what evidence-based research says, MAT is not going to be the right choice for every patient. But it is important that we understand what the intended affects and the expected results are of medication-assisted treatment.