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Innovations and Failures in Medication-Assisted Treatment

The ongoing shutdown of less than one-quarter of the United States federal government is having some unforeseen effects on the opioid addiction crisis. It will probably delay some prescriptions of the opioid replacement therapy/medication-assisted treatment buprenorphine.

That’s because buprenorphine, a far less powerful opioid than OxyContin, and which is often prescribed to wean off clients from the more powerful drug, is far more difficult to get permission to prescribe. In 2002 when buprenorphine was first allowed to treat opioid use disorder (OUD), fears that it would itself be diverted or abused resulted in prescriptions being limited to only 30 patients per medical practice.

This was later changed to 30 prescriptions per doctor, then raised to 100 and then 275 under certain stringent conditions. Physicians need permission from the government to increase the number from 30 to 100 to 275, but that permission is not being granted during the shutdown.

Why is there such fear of buprenorphine abuse? Because treating opioid addiction with another opioid is considered wrong by many people, particularly judges and politicians. They call it trading one addiction for another.

It’s not. Taken as prescribed and by someone who was already addicted to a stronger opioid—like heroin, Oxy, or Percocet—buprenorphine is unlikely to get you high. If you are a beginner opioid user, it is possible. Diversion is the real worry,

You have to take buprenorphine every day, and it is dangerous to give a month’s supply of an opioid to an opioid addict. Pharmaceutical companies tried to solve this problem by combining it with the opioid antagonist naloxone—Suboxone, first a pill, then into a sublingual film that dissolves under the tongue—that are difficult to misuse; if you try, the naloxone can cancel out the opioid.

Unfortunately, addicts are clever and reckless. They tried anyway, with some success despite the risks.

About three years ago, Titan Pharmaceuticals tried another solution: a buprenorphine implant, Probuphine: four solid matchstick-sized rods of buprenorphine that would deliver a steady dose of the drug for months. No diversion possible, no extra bupe lying around to misuse. It seemed like an almost perfect solution.

Sadly, it did not catch on, and its future seems shaky at best. Addiction medicine specialist Indra Cidambi predicted this failure in 2016, despite its advantages, based on six objections, including that clients with addictions might decide they don’t need other drug rehab treatment, such as cognitive behavioral therapy. 

They do. Addiction cannot be cured per se, so new coping skills are necessary. Even Titan said co-treatment with Probuphine is a necessity. If clients don’t need to get a refill, however, they have less motivation to do so.

Science and the pursuit of profits march on, however. The Food and Drug Administration has given tentative approval for a monthly injectable form of buprenorphine, Brixadi. Time will tell if it fares any better with physicians, insurers, and clients.

 

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