A Call For Evidence-Based Medical Treatment Of Opioid Dependence In The United States And Canada

Abstract

Despite decades of experience treating heroin or prescription opioid dependence with methadone or buprenorphine— two forms of opioid substitution therapy—gaps remain between current practices and evidence-based standards in both Canada and the United States. This is largely because of regulatory constraints and pervasive suboptimal clinical practices. Less than 10 percent of all people dependent on opioids in the United States are receiving substitution treatment, although the proportion may increase with expanded health insurance coverage as a result of the Affordable Care Act. In light of the accumulated evidence, we recommend eliminating restrictions on office-based methadone prescribing in the United States; reducing financial barriers to treatment, such as varying levels of copayment in Canada and the United States; reducing reliance on less effective and potentially unsafe opioid detoxification; and evaluating and creating mechanisms to integrate emerging treatments. Taking these steps can greatly reduce the consequent harms of opioid dependence by maximizing the individual and public health benefits of treatment.

Evidence-based treatment for opioid disorders: A 23-year national study of methadone dose levels

“…Given prior data on the performance of the nation’s MMTs; lack of nationally representative data since 2005; increased need for effective treatment of opioid abuse disorders (Nosyk et al, 2013); and prior controversy about methadone treatment (H. D. Kleber, 2008), as well as major efforts to improve treatment practices (Institute of Medicine, 1994), this paper addresses two questions.…”

“…Second, methadone maintenance is the primary treatment approach for opioid use disorders, and remains so even as other pharmacotherapies, such as buprenorphine and extended-release naltrexone, have become more available (H. D. Kleber, 2008; Nosyk et al, 2013). Finally, data from a 17-year longitudinal study of the nation’s MMTs indicate that, in 2005, more than half of patients (51%) received doses of methadone that were too low to be effective, i.e., below 60 mg/d (Pollack & D’Aunno, 2008).…”

Exploring the Public Health Impacts of Private Security Guards on People Who Use Drugs: a Qualitative Study

“…In the context of chronic health conditions such as HIV and hepatitis C infection, as well as methadone maintenance therapy for opioid dependence, 60 regular, uninterrupted access to medication dispensaries is critical for successful treatment regimens. In previous studies of traditional police forces, spatial exclusion stemming from policing practices has been shown to reduce access to health and harm reduction services among PWUD, 4,8,[17][18][19] outcomes likely produced by similar behavior by security guards.…”

Increasing Access to Medication-Assisted Treatment for Opioid Use Disorders: Estimating Costs, Supply, and the Effects of Insurance Expansions

“…To the extent that Medicaidand other publicly insured clients pick up their buprenorphine from community health centers and/or prisons, these prescriptions would not be captured in the data (and hence not reflected in the primary payer). Second, by 2012 key elements of the Federal Mental Health Parity Addiction Equity Act and the Affordable Care Act had already come into effect, presumably extending substance abuse treatment coverage to more individuals (Nosyk et al, 2013). Table 12.1 also provides a frequency count of the types of buprenorphine products and formulations that were obtained from retail pharmacies by type of plan.…”