The US House of Representatives and the Senate have each now passed bipartisan bills to fight the opioid epidemic and overdose (OD) death crisis. The two bills now have to be reconciled in conference, but the President is expected to sign the resulting bill. Action is expected this year.
There is some good to be expected from the bill. It looks like it will remove the prejudice against medication-assisted treatments (MAT) other than Vivitrol (a once-a-month injectable form of naltrexone that prevents the high from opioids), allow Medicare funding of some substance use disorders (SUD), and even encourage college graduates to enter the SUD field with a loan repayment program. Just don’t expect much additional money to become available for treatment because of the bill.
Elsewhere Congress has provided $6 billion over two years in “federal support for programs to combat the opioid crisis”. That sounds like a lot, but that includes prevention and curbing the illicit supply of drugs as well as treatment for existing addicts. Preventing the creation of new opioid addicts and the distribution of drugs are laudable goals, but they only will reduce the number of new addicts, not help those who already are addicted.
Making it harder for addicts to satisfy their addiction without increasing treatment availability is self-defeating. When addicts can’t get OxyContin, they don’t say, “Oh well, I guess I’ll get sober now”. Instead, they will try different, less safe drugs, such as heroin and fentanyl. Worse, they might take a pill that they think is OxyContin, but is actually fentanyl.
The problem with fentanyl is not only that it is 50 times stronger than heroin, but that users often don’t know they are getting it. It is easily pressed into pill form and sold as costlier and harder-to-get prescription pills. If the dealer or supplier gets the amount of fentanyl wrong, an overdose is much more likely. Even the anti-overdose drug naloxone (intranasal brand name Narcan) is only effective for fentanyl ODs in the short-term or with multiple doses.
That must be why the federal government is investing in new delivery systems for a more powerful anti-OD drug, nalmefene. It was previously marketed for alcohol addiction treatment as an injectable drug but discontinued because of low sales. Soon nalmefene may be available in an intranasal form like Narcan and a six-month implant like Probuphine (a MAT using the low-dose opioid buprenorphine).
It’s not clear why an implant is needed for a drug that should only be used when an opioid user is overdosing. Constant use might lead to tolerance for the drug, diminishing its efficacy when needed. Maintenance drugs, such as Suboxone and methadone, make more sense for implants since they are meant to be taken daily, but so far have made little headway in the marketplace.
Intranasal or injectable forms of nalmefene are logical, especially in the case of bio-weaponized fentanyl directed at dozens or hundreds all at once. For normal OD situations, naloxone remains a better choice.