Useful Tips and Resources
In addition, the identification of substance use disorders treatment as an essential benefit in healthcare reform will help to increase awareness among healthcare professionals who will increasingly need training in this area. There are also many new avenues for obtaining education in the assessment, treatment, and safe use of opioid therapies at no cost, including through programs offered by the SAMHSA and in the CSAT/SAMHSA sponsored PCSS-O and PCSS-B initiatives. The National Institutes of Health has also made excellent educational materials available through both the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism. Also, the US Food and Drug Administration (FDA) is developing an education program for prescribers on long-acting/extended-release opioids. And, of course, Medscape has been out in front on these issues and has provided many useful articles for clinicians for years now.
You ask a number of important questions. I think the low cost of methadone is attractive in terms of its use as a pain reliever. Unfortunately, many prescribers are not well informed about the clinical pharmacology of this drug, including its long elimination half-life and potential to accumulate, thus representing an overdose risk to many, as you point out. In terms of the addiction risk of buprenorphine, it is a Schedule III drug and definitely has abuse potential. In recent years, we have seen increasing diversion of this drug to street abuse and, while some of the illicit use may be related to those with opioid addiction trying to alleviate withdrawal symptoms, there is no question that many are abusing the drug for its euphoria-producing effects as well. This gets to the issue of physicians needing to be vigilant about the dosing needs of individual patients with this drug and to avoid doses in excess of what is needed to prevent withdrawal and diminish/attenuate craving. Physicians should also be aware that the FDA-approved upper dose limit of buprenorphine/naloxone (the formulation used for maintenance treatment of opioid addiction) is 24 mg/6 mg).
The issue of prescribing medications with addictive potential (other than methadone and buprenorphine for the treatment of opioid dependence, which are dosed stably and, generally, on a once-daily basis and for which those with opioid dependence develop tolerance to most opioid effects) to those with addiction is an area that requires discussion within the medical community, and those who have addictive disorders need to be educated about the risks associated with their use of prescribed medications with abuse liability that may be given by a clinician for another medical condition. Many clinicians do not understand the risk that these medications represent to a patient with a history of substance abuse who has managed to enter an abstinence-based recovery.
I think it is also the case that many patients who have stopped their substance abuse believe that they are no longer vulnerable to relapse. Again, unfortunately many with addiction who have achieved abstinence will be placed at risk for relapse if medications with abuse potential are prescribed. This is not to say that, for example, opioid pain medications should never be prescribed to those with addiction; however, a greater watchfulness over the health and safety of these individuals will be needed. Prescribers should use the medications for as brief a period as possible; it can be helpful to have a significant other hold the medications for the person, and more frequent follow-up visits with direct inquiry about problems the individual might be having with the medication use in terms of activation of craving or euphoric effects should be undertaken.
The development of a curriculum on evidence-based treatment for substance abuse would be useful in helping to reinforce principles of care regarding assessment and treatment of substance use disorders -- understanding the use of and interpretation of urine toxicology screens is an important part of such a curriculum. The California Academy of Family Physicians has developed a 2-hour CME course available at no cost on this topic that is excellent.
Those of us who have worked with impaired health professionals know that the strict monitoring and individualized treatment approaches have met with good success in this population. However, it is also the case that many impaired professionals have much to lose in relapse and so often have high levels of motivation for treatment. I think motivation for treatment is very important to success in the treatment of substance use disorders. I think that unless there is a motivation for discontinuation of substance use, which is not the case with everyone who enters a substance abuse treatment program, it will be quite difficult to translate the success of impaired health professionals treatment/monitoring programs to the general public.