Medical Leaders: Elevate Evidence Over Bias in Opioid Disorder Treatment

An editorial co-authored by experts at Boston Medical Center and published last week in a primary care journal takes aim at restrictive government regulations and lingering provider biases that hinder access to two of the three approved medication treatments for opioid dependence.

The editorial, published online Dec. 18 in the Annals of Internal Medicine, argues that the tendency for some to question the use of the agonists methadone and buprenorphine flies in the face of compelling research evidence. This includes a study, also recently published in the same journal, that found the combination of buprenorphine and naloxone to most likely be more cost-effective than the opioid antagonist naltrexone in its injectable form.

Naltrexone, however, has become the favored medication option in some justice systems, addiction treatment programs and recovery support groups—largely because it is not an opioid. This is the case despite the challenge of having a prospective patient remain opioid-free for a week or more before they can start on the medication—an issue that means many individuals are never able to be successfully inducted on the antagonist.

“By offering only naltrexone—a medication that most persons either will not receive or not continue—because of clinician or institutional beliefs, patients receive inferior treatment,” wrote co-authors Joshua A. Barocas, MD, and Richard Saitz, MD, MPH, both with Boston Medical Center and the Boston University School of Medicine. Saitz is also a professor in the Department of Community Health Sciences at the Boston University School of Public Health.

Call for educational campaign

Barocas tells Addiction Professional that he believes it will take more than a set of compelling research data to convince some prescribing professionals and members of the public that someone taking an agonist to combat opioid addiction is not “addicted” to the medication. He thinks a concerted educational campaign also is needed.

“We should always go back to the comparable chronic diseases,” Barocas says. No one questions a cardiovascular disease patient's need to take aspirin after a heart attack, or a blood pressure medication to control hypertension, he says.

“Just because your body requires something, that doesn't mean it's not treatment,” says Barocas.

The editorial cites the American Society of Addiction Medicine (ASAM) definition of abstinence, as “intentional and consistent restraint from the pathological pursuit of reward and/or relief that involves the use of substances and other behaviors.” The editorial states that by this measure, using methadone or buprenorphine to remain abstinent from illicit opioids constitutes abstinence.

The barriers to care resulting from longstanding biases won't be broken simply by having some leaders talk to already like-minded colleagues, Barocas says. The patients most affected by the opioid epidemic and in a position to benefit most from medication interventions that facilitate recovery need to have a platform, much as activists did to make HIV/AIDS a front-burner issue in the 1980s and 1990s, he suggests.

He adds that there are signs of incremental progress, including with the expansion and increased accessibility of provider training for the purpose of receiving the required federal waiver to prescribe buprenorphine.

Still, with the provision of both methadone and buprenorphine treatment still subject to strict federal controls, it remains true that “we don't see these regulations for literally any other chronic condition,” says Barocas.

The evaluation of treatment options for opioid addiction, the authors of the editorial suggest, should consider issues of efficacy, cost, risks and the likelihood of success. “Basing medical decisions on beliefs about medications does nothing to help the growing pool of those with [opioid use disorder], who if untreated are likely to fall victim to an overdose.” they wrote.