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Medication-Assisted Therapies--Tackling the Opioid-Overdose Epidemic.

Volkow N D, et al.

Journal: N Engl J Med. 2014; 370:2063-2066. 5 references. 
Reprint: Nora D Volkow, MD, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD. 
Faculty Disclosure: Abstracted by N Walea, who has nothing to disclose.

Editor's Note:
There are three types of medication-assisted therapies (MATs) for treating patients with opioid addiction: methadone, buprenorphine, and naltrexone. Of the 2.5 million Americans who abused or were dependent on opioids in 2012, fewer than one million received MAT. This enlightening article gives us awareness and information about handling an extremely difficult and timely problem. Please note the New England Journal is represented this month about opioid concerns adding to the pain journal chorus.

Class: Pharmacology: Opiods

Prescription opioids were involved in 16,651 overdose deaths in 2010 alone. The health and economic costs are similar to those associated with other chronic diseases such as asthma and HIV infection. HHS agencies are implementing a comprehensive, coordinated effort to address the key risks involved in prescription-drug abuse, especially opioid related overdoses and deaths. There are four main objectives: 1) to provide prescribers with the knowledge to improve prescribing decisions and the ability to identify patients' problems related to opioid abuse; 2) to reduce inappropriate access to opioids; 3) to increase access to effective overdose treatment; and 4) to provide substance-abuse treatment to persons addicted to opioids.There are three types of medication-assisted therapies (MATs) for treating patients with opioid addiction: methadone, buprenorphine, and naltrexone. Of the 2.5 million Americans who abused or were dependent on opioids in 2012, fewer than one million received MAT. MATs have proven to be effective in helping patients recover when prescribed and monitored properly. Some MATs increase patients' retention in treatment, all MATs improve social functioning as well as decrease the risks of infectious-disease transmission and of participation in criminal activities. However, MATs have been adopted in less than half of private-sector treatment programs and in those that offer MATS, only 34.4% of patients receive them.Barriers to access and utilization of MATs include a scarcity of trained prescribers and negative attitudes and misunderstandings about addiction medications by the public, providers, and patients. One common concern is that MATs just replaces one addiction with another. Many managers and staff of treatment-
facilities favor an abstinence model, and provider skepticism may contribute to the low use of MATs. Policy and regulatory barriers are another problem. Utilization-management techniques, such as limits on dosages prescribed, annual or lifetime medication limits, initial authorization and reauthorization requirements and "fail first" criteria, are some of these barriers. Some commercial insurance plans, while covering MATs, limit access to a limited number of in-network providers and most do not cover methadone provided through opioid treatment programs.It is hoped that implementation of the Affordable Care Act (ACA) will increase access to care for many Americans, including persons with addiction. The National Institute on Drug Abuse (NIDA is funding research to improve delivery of MATs to vulnerable populations and is also working to develop new pharmacologic treatments for opioid addiction and helping to fund "user friendly" delivery systems for naloxone (intranasal rather than injection). The CDC is working to help states implement comprehensive strategies focusing on enhanced surveillance, effective policies and clinical practices that establish statewide prescribing norms.

Important Points:

The epidemic of prescription-opioid overdose is a complex issue. A crucial component of the effort to help patients recover is to expand access to MATs. It is also necessary to implement prevention of inappropriate prescribing of opioids while avoiding jeopardizing critical or even lifesaving opioid treatment when it is needed. Physicians will need to reduce unnecessary or excessive opioid prescribing, check data from monitoring programs to identify patients who may be misusing opioids and take full advantage of MATs for people with opioid addiction.

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