The Science and Practice of Medication-Assisted Treatments for Opioid Dependence

Abstract

This paper briefly reviews the evolution of opioid addiction treatment from humanitarian to scientific and evidence-based, the evidence bases supporting major medication-assisted treatments and adjunctive psychosocial techniques, as well as challenges faced by clinicians and treatment providers seeking to provide those treatments. Attitudes, politics, policy, and financial issues are discussed.

Keywords :

• opioid addiction
• methadone
• buprenorphine
• heroin
• diamorphine
• history

THE AUTHORS

Anna Pecoraro, PsyD, is a clinical psychologist and research associate in the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, and is a co-investigator with the Delaware Valley Node of the NIDA Clinical Trials Network. An operatic soprano with a bachelor of music degree from Westminster Choir College in Princeton, NJ, she subsequently earned masters and doctoral degrees in clinical psychology from the Institute for Graduate Clinical Psychology of Widener University in Chester, PA, with concentrations in cognitive behavior therapy and health psychology. Dr. Pecoraro completed her postdoctoral fellowship in addictions at the University of Pennsylvania. Dr. Pecoraros research interests include treating opioid and alcohol addiction, preventing HIV treatment attrition, and improving medical care by providing SBIRT services in medical contexts. As a clinician and researcher, Dr. Pecoraro is particularly interested in what scientists can learn from listening to patients tell their own stories and learning how peoples strengths and positive characteristics can be used to address their needs. She has collaborated in both domestic and international research in St. Petersburg Russia and Kiev, Ukraine.

Michelle Ma, BA, earned her Bachelor of Arts in biology with a minor in psychology from the University of Pennsylvania in 2009 and is currently pursuing an MD at the University of Michigan Medical School. She has previous research experience in tumor virology at the University of Pennsylvania School of Medicine. Her research interests include substance abuse, infectious disease, HIV, and health inequities. In 2010, she traveled to the Dominican Republic with Health in Action, a University of Michigan student group, where she distributed health education materials she helped to develop. In her free time, she enjoys visiting high schools in Michigan to teach students about HIV/AIDS and performing Bhangra with her Indian dance group.

George Woody, MD, is Professor in the Department of Psychiatry at the Perelman School of Medicine, University of Pennsylvania, and Principal Investigator of the Delaware Valley Node of the NIDA Clinical Trials Network. He lives in Philadelphia with his wife Christina, and they have two children, Nicholas and Christina. He reviews papers for many journals, has authored or co-authored over 200 publications including a recent JAMA publication on Suboxone treatment of opioid addicted youth. He was a member of the DSM-IV Work Group on Substance Use Disorders and the FDA Drug Abuse Advisory Committee, has been co-editor of Treatment Improvement Protocols on methadone maintenance, and is a member of research groups studying the abuse liability of prescription opioids. He has been involved in studies on various aspects of substance abuse and HIV risk in Brazil, Germany, Iceland, Indonesia, Republic of Georgia, Russia, and Ukraine. He has lectured nationally and internationally and was awarded a Doctor Sui Causa from Pavlov State Medical University in St. Petersburg, Russia in September 2003, and received an award in honor of Dr Alexei Alexeevich Likhachev, founder of the Pharmacology Department of the Women's Medical Institute of St. Petersburg, Russia, later renamed Pavlov State Medical University, in February 2009. Hobbies are skiing, tennis, swimming, and traveling.

Notes

1 The reader is reminded that SUDs are a consensualized diagnostic outcome of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 4th Ed.; American Psychiatric Association: Washington, DC, 1994. Recent “medicalization” of “drug use” which does not sufficiently serve basic diagnostic purposes of gathering empirically based relevant information in order to make a needed clinical decision nor give the minimum of needed evidence-based information: etiology, process, and prognosis. Editors note.

2 Initially assisted with hot baths during the day and chloral hydrate for sleep; assisted with methadone after 1948.

3 Robinson v. California was a decision regarding the constitutionality of a California statute making the state of being addicted a crime. The decision reads, “… a law which made a criminal offense of such a disease would doubtless be universally thought to be an infliction of cruel and unusual punishment in violation of the Eight and Fourteenth Amendments.”

4 The reader is asked to consider that treatment can be briefly and usefully defined as a planned, goal directed, temporally structured change process, of necessary quality, appropriateness, and conditions (endogenous and exogenous), which is bounded (culture, place, time, etc.) and can be categorized into professional-based, tradition-based, mutual-help based (AA, NA, etc.) and self-help (“natural recovery”) models. There are no unique models or techniques used with substance users –of whatever types and heterogeneities –which aren't also used with non-substance users. In the West, with the relatively new ideology of “harm reduction” and the even newer Quality of Life (QOL) treatment-driven model, there is now a new set of goals in addition to those derived from/associated with the older tradition of abstinence driven models. Treatment is implemented in a range of environments: ambulatory, within institutions, which can include controlled environments. Editor's note.

5 Descriptions of MMT as well as other substance user treatments in the literature can easily be read as suggesting linear “cause and effect” relationship dimensions. The reader is referred to Hills's criteria for causation that were developed in order to help assist researchers and clinicians determine if risk factors were causes of a particular disease or outcomes or merely associated. (Hill, A. B. (1965). The environment and disease: associations or causation? Proceedings of the Royal Society of Medicine, 58, 295–300.) Editor's note.

6 In France, buprenorphine is prescribed by family physicians.

7 In the USA, buprenorphine is prescribed by specially trained physicians with a “waiver” to prescribe it. They are limited to treating 30 patients during the first year and up to 100 in subsequent years, after obtaining an additional waiver (CSAT Buprenorphine Information Center, 2010).