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Optimizing Opioid Addiction Treatment
Opioid treatment programs (OTPs; methadone maintenance programs) are state and federally licensed programs to use methadone to treat opioid addiction. They cannot be the focus for treating pain due to legal and licensing requirements. However there is no doubt they have a role in treating the addiction component in coordination with physicians who manage pain. The issue about access is largely determined by funding and state regulations. Most OTPs have a waiting list to treat opioid addiction and are not resourced or have the expertise to broaden their referral base to accept patients with pain and addiction problems. I agree that quality of care in OTPs is variable and there is definitely scope for best practices, in particular for treatment of comorbidity, and use of benzodiazepines and nonpharmacologic treatments. All OTPs have to undergo Commission on Accreditation of Rehabilitation Facilities surveys for quality assurance purposes.
The field is changing with the introduction of Suboxone® (buprenorphine-naloxone combination), which is a partial agonist that is much safer in overdose than methadone, less addictive, and is less likely to be injected due to risk of precipitating withdrawal. It can be prescribed by qualified physicians (under a special Drug Enforcement Agency license) from their offices to treat opioid addiction as opposed to methadone, which cannot be prescribed to treat opioid addiction outside of an OTP.
I think the way to expand treatment for opioid addiction is to train physicians so that they become qualified to prescribe Suboxone® properly rather than simply expand methadone programs. Data from France found that after introduction of buprenorphine, there was a 79% reduction in opioid overdose deaths -- largely due to buprenorphine being used instead of methadone -- and that methadone consumption has 3 times the death rate of buprenorphine.
Several National Societies (eg, The American Society of Addiction Medicine, American Academy of Addiction Psychiatry) offer in-person as well as online training courses for physicians to meet the requirements to obtain the Drug Enforcement Agency license to prescribe office-based Suboxone®. The American Society of Addiction Medicine also has an excellent, free physician support system (PCSS) that is supported by the Substance Abuse and Mental Health Services Administration to answer questions about buprenorphine, methadone and safer opioid prescribing (www.PCSSmentor.org or 1-877-630-8812). Depending on the location of the physicians, the PCSS system matches them up with a local expert (mentor) who serves as a no-cost consultant. I encourage physicians who are interested in treating opioid addiction to first obtain the necessary training and license and then make use of the PCSS system when necessary. I am one of the mentors for the southeast region, and the system works great.
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