Opioid Abuse Disorder is a Medical Disease, and It Can be Treated
By Rae Brown, MD, FAAP
Professor of Anesthesiology and Pediatrics
University of Kentucky/UK Healthcare
Chair, FDA Advisory Committee on Analgesics, Anesthetics, and Addiction Products
Opioid Abuse Disorder (OAD) is a recognized medical disease. As with most medical disorders, OAD reflects biological and behavioral roots. Patients can develop OAD because of acute injury treated with medications prescribed by a physician. Indeed, opiates are important in the treatment of patients with pain; and it is unlikely that we will be able to adequately treat moderate to severe pain in the foreseeable future without this class of drugs. Opiates, however, even when prescribed for painful conditions, carry the risk of dependence or addiction in any patient. There is no safe dose, no safe opioid agent, no safe patient. In many ways, a patient with opioid abuse disorder is like an adolescent with diabetes. These patientscommonly require intensive therapy and close supervision to maintain stable blood sugars. This treatment must be ongoing with careful observation and changes over time in medical management. Some patients discontinue their medications abruptly and become acutely ill. When this occurs, physicians start over again; they do not forsake their patient or judge them to be immoral. Medical management for diabetes is effective when provided by expert clinicians, the same is true of opiate addiction.
Opioid abuse disorder is a chronic relapsing disease and this disease must be treated medically, along with supportive social and psychological intervention. The scope of this article has been limited to the specifics related to medical management of OAD. Medical treatment will most often have, as a foundation, continued and long term management with methadone, buprenorphine, or other similar drugs under the strict supervision of trained professionals. This is the only treatment that has been demonstrated to be effective. There are no other treatments that allow patients with this disorder to reenter the mainstream as functional, responsible adults. Every other treatment, when used alone, has failed.
As with all disease processes, patients may or may not obtain treatment; if they do not, the outcomes are abysmal, and for many the outcome is death. The failure to get medical treatment occurs for a variety of reasons. Among those are the lack of availability of trained clinicians in settings that can provide ongoing and long term support. Such is the case in Kentucky, Indiana, West Virginia, and Ohio; states especially hard hit by the current wave of opioid abuse. Unfortunately, even when medical treatment is available, there is pressure to focus on therapy based on faith, short term detoxification, or twelve step programs. For alcohol, for some patients, these may be effective and alcohol does not kill rapidly. For opioids, these abstinence based treatments have been shown to be ineffective and to dramatically increase the risk of death. At present, Kentucky, Indiana, Ohio, and West Virginia are ground zero for the lack of adequate medical treatment resources, and a strong cultural bias in favor of faith based therapy and half way houses. Under these circumstances, we should expect to see more opiate deaths despite all other current efforts.
In the United States, our current drug crisis has caused death, dramatically increased the number of patients with hepatitis C, been a primary trigger for the dissolution of families, and caused hundreds of children to be born addicted to opioids. If we cured the disease today, we would still have an entire generation of infants, children, and adolescents that have never had nor will ever have a normal life. This does not bode well for the future of our country. The consequences for our future are staggering.
One unfortunate consequence of failure to obtain medical treatment is often exposure to the criminal justice system. Inevitably, rather than shunting these patients to treatment programs they are incarcerated and this leads to further exposure to the drug culture and an education about new drugs and other methods to support their habit. Failure to obtain medical treatment frequently leads to an acceleration of the need for opiates, injection, and the sharing of needles.
Patients that do receive the best medical care, including long term support with methadone or buprenorphine can do very well. Most, however, require intense supervision and support. Even with all of the methods of drug treatment and psychological and social support applied to the best of our ability, some will intermittently return to opioid use and abuse. Some will even accelerate their previous behaviors and some will subsequently die. But the debate about how to reduce the deaths from opiates is largely over; more of our friends, our children, and our loved ones will die if not provided medical treatment. Any other method of management is ineffective and courts a continued disaster.
Because of the massive exposure of Americans to prescription opioids, heroin, and other compounds, we are living in a time when death from opioids is too common. For this terrible disease, there are no guarantees. However, the risk of not using our resources to provide the right treatment, aggressive medical management, is too high to consider otherwise. We cannot continue to follow the path that we are on, believing that people with the disease, some our friends and loved one's, can fight this battle by themselves. Opioid abuse disorder is established in the US, but with expert medical care including opioid support, many, if not most patients can lead healthy productive lives. Once established, like alcohol abuse, it will not be cured. But with focus and resources, we can do a much better job of reducing the impact of the disease and diminishing the number of citizens in the next generation that are affected.