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OMA Medicine in OR Winter 2015 2016

SPOTLIGHT ON Viable Options Medication-Assisted Treatment By Amy Kerfoot, MD, MBI THE NATION’S OPIOID EPIDEMIC continues to rage. The epidemic spans all ages, genders, ethnicities, income levels, and geographic regions. In addition to direct loss of life, substance abuse leaves a swath of related issues: criminality, domestic violence, homelessness, unemployment, accidents, worsened mental illness, inappropriate utilization of medical resources, neonatal abstinence syndrome, and spread of viral hepatitis and HIV. While policy efforts are underway at all levels to reduce opioid misuse, the fact remains that thousands are already addicted. Substance abuse is a chronic, relapsing disease, with successful treatment involving both counseling and medication. The Substance Abuse and Mental Health Services Administration (SAMHSA) is the federal agency tasked with coordinating this public health effort. Estimates identify over 20 million Americans with unmet treatment needs, representing society’s While policy efforts are underway at all levels to reduce opioid misuse, the fact remains that thousands are already addicted. most vulnerable members. Sadly, they may be stigmatized and publicly shunned, even by the medical community. Yet, appropriate therapy can result in sustained, meaningful recovery. Medication-assisted treatment (MAT), refers to the combination of behavioral therapy and prescription medication, generally through a supervised Opioid Treatment Program (OTP). Traditional MAT comes in three unique “flavors.” All work to reduce withdrawal symptoms and cravings, while reducing the ability to get high. They are generally covered by private insurance and by the Oregon Health Plan. 1. Methadone The best-known is methadone, a full muopioid agonist with a half-life of roughly 36 hours. Evidence shows it to be highly effective in maintaining abstinence, and relatively safe when taken as prescribed for maintenance, even in pregnant women. Methadone requires daily oral dosing in a structured OTP, making it the best choice for patients with a history of heavy or injection drug use, or an unstable social situation. While it carries the risk of overdose or serious side effects (cardiac arrhythmias), 2014 CDC data show the death rate involving methadone remained unchanged; while that involving other opioids (e.g., fentanyl) increased nearly 80 percent. It may be used for months to years, though it is not a first-line choice for chronic pain. 2. Buprenorphine Another treatment option is buprenorphine, a partial opioid agonist working similarly to methadone. An oral daily medication, it is often formulated with Naloxone (overdose reversal) to deter abuse. Buprenorphine was approved in 2002 for outpatient prescribing and dispensing, offering significant treatment capacity implications. Physicians must obtain a prescribing waiver through SAMHSA following training (available online). The well-prepared outpatient office (staff education, urine drug screens, relationship with behavioral health professionals) can manage a small panel (30 patients per physician, may extend to 26 Medicine in Oregon www.TheOMA.org


OMA Medicine in OR Winter 2015 2016
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