Methadone not forgotten as health officials push for buprenorphine expansion

While municipal public health officials who addressed the opioid crisis at a Capitol Hill briefing this week focused their medication treatment comments on buprenorphine, they add that methadone must not be lost in the equation.

In an e-mailed response to questions from Addiction Professional, Boston Public Health Commission executive director Barbara Ferrer, PhD, said that addiction “should be treated like any other chronic disease—like diabetes, hypertension or heart disease.” There is no one path to recovery, she said, adding that all “treatment options, including methadone, should be available to patients.”

But additional emphasis on buprenorphine is necessary at this time “because we see an opportunity for improved access to this treatment,” she said, referring in part to a legislative initiative to remove limits on who can prescribe buprenorphine and to how many patients.

Fellow briefing panelist Bechara Choucair, MD, Commissioner of the Chicago Department of Public Health, agreed, saying that “every possible solution must be on the table—including the use of methadone as a harm reduction strategy.” The more than two dozen methadone clinics in Chicago are evenly divided between a public and private funding base, Choucair says.

“Research has demonstrated that methadone maintenance treatment is an effective treatment for heroin and prescription narcotic addiction—slashing injection rates, lethal overdose, and crime rates, as well as reducing HIV transmission, time spent unemployed, and time spent incarcerated,” he says. Clearly, [opiate treatment programs] must be part of our treatment options.”

“OTPs are absolutely part of the solution in New York City,” adds Hillary Kunins. MD, Assistant Commissioner for Alcohol and Drug Prevention & Treatment with the New York City Health Department, who did not speak at this week's briefing but submitted comments later to AP. “Generally, we need a system that serves people through multiple pathways. While some will do well with buprenorphine, others will do better with methadone.”

Kunins notes that in New York City there is ample capacity to reach many people through the well-established OTP system, adding that “some OTPS have robust recovery support, counseling and primary care services available on-site that make them appealing.” She adds that an increasing number of OTPs are offering buprenorphine as well as methadone, which “has the advantage of pairing buprenorphine with the additional support services that are available at OTPs.”

Medication holdouts

The Big Cities Health Coalition, which hosted this week's event and used the occasion to lend its support to a bill in Congress that would expand access to buprenorphine, seeks to deliver a strong message to those treatment providers—and others in the public policy arena—who are philosophically opposed to buprenorphine and methadone.

“We believe strongly that patients experiencing addiction should have access to all available, evidence-based treatment options,” says Ferrer. “We also understand the hesitancy some addiction professionals have in supporting medication-assisted treatment. It’s important to understand that abstinence may not work for everyone and that individuals who are addicted to opioids or who are engaging in poly-drug use may require medication-assisted treatment to be successful. Our goal as providers should be to help patients make the best choice for themselves, rather than to substitute our judgment in place of theirs.”

Choucair's comments reflect his mindset as a physician: “My treatment philosophy is to review the best medical evidence available and prescribe evidence-based treatments that achieve positive long-term outcomes for the patient and society. Addiction is a disease and not a character flaw. People dealing with addiction should be offered treatment and not punished.”

Kunins adds, “Medication-assisted treatment, with such medicines as methadone and buprenorphine, is the most effective treatment for opioid addiction. These medications reduce deaths from opioids, drug use, and crime, and, most importantly, help individuals regain their ability to participate in their communities, families, and workplaces. Research has demonstrated that patients have better outcomes if they are treated with these medications for longer vs. shorter periods of time. This makes sense because addiction is a chronic disease, just like high blood pressure or diabetes.”