The 2016 Ohio Opioid Use Guidelines: What Are They, Why We’re Here, When Do They Come into Their Own, and How Do They’re Used?
After the 2016 guidelines were released, the decline in the number of Opioid prescriptions continued. There’s widespread agreement that opioids should be used cautiously because of the risks associated with addiction and overdose. Fentanyl and other narcotics are the main cause of overdose deaths, but not as much as in the past.
Patients who are abandoned to withdrawal and untreated pain have an increased overdose death risk of nearly 300 percent, and their risk of suicide is also significantly elevated. If thousands of them had not been cut off, the enormous street Fentanyl market that now exists might not exist. It is unethical to increase patients’ risk of overdose deaths in order to reduce these harms.
Federal agencies made it clear that voluntary guidelines were not meant to become strict policies or laws. But doctors and patient advocates also held out hope that the CDC’s updated guidelines would undo some of the unintended consequences of the earlier guidance.
The updated guidelines are voluntary and intended to guide decision making between clinicians and patients, according to Chris Jones, an acting head of the CDC’s National Center for Injury Prevention and Control.
The new guidelines have a change in outlook according to Dr. Narouze.
The voluntary guidelines are a positive step, if followed by state and federal agencies, according to the health in justice action lab director at Northeastern University.
The definition of high-dosage use is used in the 2016 recommendations to establish legal limits. He says the 2016 guideline was clear that it’s not a bright line rule, but it became 888-282-0465 888-282-0465 888-282-0465 888-282-0465 888-282-0465 888-282-0465. And this led law enforcement in some states to use the limit “as a sword to go after prescribers.”
There has been a chilling effect on doctors as a result of the doses and limits that have been set.
According to Dr. Antje Barreveld, director of Pain Management Services at the hospital, they are very comprehensive and compassionate. “Those arbitrary marks of what’s acceptable and not acceptable is what got us into trouble with the 2016 guidelines, because it made this blanket cut off for our patients and that’s not what pain management is about.”
Reducing opiate use when possible still raises some concerns for clinicians like Kertesz, a professor at the University of Alabama at Birmingham.
Kertesz says that when taking a stable patient and reducing their prescription, you’re engaged in an experiment. Dose reduction is an uncertain intervention that can cause the patient to die. I’d rather they said that this is an uncertain intervention.
However, he adds that the strength of the new guidance is its repeated emphasis that a specific dose should not be used by agencies, law enforcement and payers to enforce a one-size fits all approach.
Are Dose Thresholds in the Prescription of Opioid Use Disorder Governed by Policies or Practice?
“We’re expected to care for patients with diabetes or to care for patients with heart attack in a certain way and the same should be true for patients with an opioid use disorder,” says Wakeman.
The previous guidelines led to restrictions on prescribing being codified as policy or law. Even though the guidelines state they are not intended to be implemented as absolute limits for policy or practice, it’s not clear whether those rules will be re-written.
“That is a good idea, but it won’t have an effect unless the agencies act immediately,” says Kertesz. “The DEA, the National Committee for Quality Assurance, and the Centers for Medicare and Medicaid Services, all three agencies use the dose thresholds from the 2016 guideline as the basis for payment quality metrics and legal investigation.”
The MAT Act would eliminate the special Drug Enforcement Administration waiver that doctors must apply for in order to prescribe buprenorphine (a medication that helps reduce the craving for opioids). As long as it is written for by a doctor through telemedicine, it would be possible for community health aides to give this medication. And it would give the Substance Abuse and Mental Health Services Administration responsibility to start a national campaign to educate health care practitioners about medications for opioid use disorder. Data has shown that these medications can be used to prevent overdoses, and addiction specialists agree that this is one of the best options for people in recovery. But a 2019 report from the National Academies of Sciences, Engineering and Medicine found that less than 20 percent of people who could benefit have access to them.
“Removing the X-waiver,” says Hansen, “is not in itself going to revolutionize the opioid overdose crisis in our country. We would need to do more.
An update on opioid overdose deaths and the need for first responders and naloxone: The U.S. opioid crisis as a public health problem
The House passed the MAT Act as a part of a broader mental health package.
As a result, drug overdoses are both a major public health problem in their own right — they are one reason U.S. life expectancy fell in 2020 and 2021 — and representative of the system’s larger struggles. The U.S. spends far more per person on health care than any other country and also has lower life expectancy than Canada, Japan, South Korea, Australia and much of Western Europe.
The latest data showed that the majority of overdose deaths were caused by synthetic opioids. meth was involved in almost a third of the cases.
According to a statement from the White House Office of Drug Control Policy, meth and fentanyl are often found together with other drugs.
There are many more nonfatal overdoses than there are fatal overdoses and last week a new dashboard was released by the Biden administration.
Obtaining and monitoring more real-time data on opioid overdoses that do not end in death could help predict where overdose deaths are more likely to happen and where there might be an increased need for first responders as well as the life-saving medication naloxone, which temporarily reverses the effects of an opioid overdose, Gupta said last week.
According to Gupta’s statement from Wednesday, emergency medical services responded to more than 390,000 activations nationwide that involved the administration of naloxone in the 12-month period ending in July – nearly four for every fatal overdose in the same timeframe.
Hundreds of thousands of pounds of drugs have been seized by the US Customs and Border Protection.
Access to Life-saving Treatment for Substituted Substances During the Victims of the Pandemic: A Study by Dr. Linda Wang
“If somebody has access to these life-saving medications, it cuts their mortality risk by 50 percent,” says Dr. Linda Wang, a researcher who treats patients with addiction at Mount Sinai Hospital in New York City.
Public health agencies say that only one in 10 Americans struggling with addiction receive treatment. Access to treatment can be difficult for people of color.
The policies made millions of people vulnerable as the powerful, toxic synthetic opiate Fentanyl began to spread in the us.
“There were significant barriers that were quite stigmatizing for patients as they enter treatment,” says Dr. Neeraj Gandotra, chief medical officer for the Substance Abuse and Mental Health Services Administration (SAMHSA), the federal agency that oversees addiction.
Gandotra points out even people who do manage to get methadone are often forced to visit a government-approved clinic multiple times a week to get doses.
The ability to only go to the clinic if they need a dose is a significant hurdle, said Gandotra.
There was no evidence that diversion increased or risk increased, but people who gained access to treatment did better.
The rule-change proposed by the Biden administration would make those reforms permanent. It would also eliminate waiting periods for access to methadone and expand telehealth options even further.
Gandotra says that the term “detoxification” will not be used in SAMHSA rules for opioid treatment programs.
She credits methadone for allowing her to stabilize her life and go back to school, where she’s about to get her PhD in justice studies at Arizona State University.
But she also says she’s faced years of stigma and surveillance within the opioid treatment system, where she often felt less like a patient and more like a criminal.
During the pandemic, Russell says she was finally allowed to take home a month’s supply of her medication at a time. She used to go to the nearest clinic daily, but that was not possible due to that.
For now, the only way to get access to methadone is through a limited number of certified treatment programs.
Government officials and addiction experts believe the ultimate goal is to regulate the painkillers like drugs for other chronic diseases.
The State of the Art: Opioid Rapid Response Program in Alabama for Addiction Patients, Medication Over the Counter, and How to Avoid Suspensions
I think it’s too early to say if the rule change is a step towards that. We believe it is, but I have to say I’m not sure how far along we still have to go,” Gandotra said.
She contacted a lot of doctors trying to find care. She said that the C.D.C. had an Opioid Rapid Response Program which was meant to help when pain clinics were shut down or large numbers of patients lost doctors. “It was almost like they thought I was out of line, even ridiculous, for calling them,” she said. The program has difficulty finding physicians to help patients like this, and is in the early stages of considering some proposals to study why they get rejected.
Patient advocates say that the answer is simple: Doctors who are willing to take a lot of pain patients who need opioids are scared of being sued by the government. Even if they are pain specialists, doctors with more than a few high-dose patients will stand out in the database.
People who suffer pain cannot be blamed for America’s addiction problem. Denying them access to needed medication helps no one. At least one man and his wife have already died by suicide following the closure of the clinic Ms. Fuqua attended.
Only licensed physicians are allowed to distribute the drug in Alabama. Such restrictions can make it more challenging for harm-reduction groups to buy the medication in bulk. That’s where over-the-counter Narcan could make a big difference, said Maya Doe-Simkins, co-director of the Remedy Alliance, a nonprofit naloxone distributor.
The FDA is considering how to handle an application from Emergent BioSolutions to sell Narcan over the counter.
Because of the rapid death rate of fentanyl, the benefits of taking buprenorphine and other drugs to treat an opiate use disorder have increased. Buprenorphine is present in a small percentage of overdose deaths nationwide, 2.6% – virtually always with a mix of other drugs, often benzodiazepines. In Massachusetts the rate of Fentanyl overdose deaths is very high.
Experts say naloxone is a safe, effective, easy-to-use medicine that works if administered within the first few minutes of an overdose, with no potential for abuse. The medication works by binding to the same brain receptors as opioid, counteracting their effects.
“For the sake of the public and saving lives, I believe this medication should be available over the counter to the public as soon as possible,” said Dr. Katalin Roth, a professor of medicine at the George Washington University School of Medicine & Health Sciences, after Wednesday’s panel vote.
“For people who can afford the formulations of Narcan that are advancing towards over-the-counter status, I think this is a step forward to naloxone access,” said Dr. Brian Hurley, an addiction physician and president-elect of the American Society of Addiction Medicine. More pathways are needed for people to reverse overdoses.
He stated that this would not solve the issue of getting the drug to under-resourced individuals and families, because they have to pay for it.
Prioritizing a medication that can save lives, she said, helps chip away at the stigma people who use drugs often face — stereotypes that can lead to discrimination against communities and distract from efforts to confront the crisis.
She said that it means that we’re getting past stigma and that we’re starting toaddress the fact that there are solutions that are within our grasp. “We’re not helpless in the face of this crisis.”
Some of the problems are specific to addiction. But others are broader. Mental health conditions, as well as Obesity, are often under treated. Flu seasons are consistently worse than they have to be because not enough people get their annual shots. Underuse is a problem that many people don’t know about, even though Americans frequently misuse health care.
More deadly forms of the drug can be treated with buprenorphine, which is a partial agonist and is not recommended for treating addiction.
The X-waiver moment of the American health care system: How many patients are willing to prescribe buprenorphine?
It is easier to have problems in the American health care system. In France, officials can leverage the country’s universal health care system to overcome hesitancy to new treatments by guaranteeing they’re widely available and by strongly pushing for their use. In the U.S. system, there is no centralized authority, so medical authorities struggle to coordinate care even when the best practices seem clear.
Clinicians who wanted to prescribe the medicine had to complete an 8-hour training. They could only treat a limited number of patients and had to keep special records. They were given a Drug Enforcement Administration (DEA) registration number starting with X, a designation that many doctors say made them a target for drug enforcement audits.
“Just the process associated with taking care of our patients with a substance use disorder made us feel like, ‘boy, this is dangerous stuff,’” says Dr. Bobby Mukkamala, who chairs the American Medical Association’s task force on substance use disorder.
The rigamarole is mostly gone. The “X-waiver” became a thing of the past when Congress eliminated it last year. This is what addiction experts refer to as a truth serum moment.
The number of doctors who were approved to prescribe buprenorphine more than doubled from 2016 to 2022, after the state told physician training to include an X-waiver. Jody Rich, an addiction specialist who teaches at Brown University, says that the option to prescribe buprenorphine didn’t open the floodgates for patients in need of treatment. In Rhode Island the number of patients taking buprenorphine increased but at a slower rate than in previous years.
Gupta and others envision obstetricians prescribing buprenorphine to their pregnant patients, infectious disease doctors adding it to their medical tool box, and lots more patients starting buprenorphine when they come to emergency rooms, primary care clinics and rehabilitation facilities.
Dr. Sarah Wakeman is the medical director for substance use disorder atMass GeneralBrigham in Boston.
Black patients make up 15% of the patients at the New Boston health center, but only a tiny percentage are taking buprenorphine. For Hispanics that comparison is 30% to 23%. Most of the health center patients are white, and just a little more than half of all patients are white.
The truth experiment that will test whether clinicians will now step up their prescribers is going on in hospitals and clinics across the country.
Jamie Simmons, the registered nurse who runs the center’s addiction treatment program, began Kim’s visit in an exam room. NPR agreed to use only Kim’s first name to limit discrimination linked to her drug use.
Kim told Simmons buprenorphine helped her stay off heroin and avoid an overdose for nearly 20 years. Kim takes a brand of the medication called Suboxone, which comes in the form of thin film-like strips she dissolves under her tongue.
Kim says that it was the best thing that could have happened, since she has been taking them.
Buprenorphine can produce some positive effects but there’s a limit to it. Patients like Kim may develop a tolerance and not experience any effects.
“I’ve seen so many people fall out [overdose] in the last month,” says Kim, her eyes wide, “that stuff is so strong that within a couple minutes, boom.”
Kim doesn’t think that she was intending to ingest Fentanyl. She thinks it could have been cocaine, she said her roommate shares it occasionally. Kim says she takes a sleep medication. Many primary care doctors don’t have the experience handling drug issues like hers. Some clinicians are hesitant about using an opiate to treat an addiction, despite the fact that it saves lives.
“You wouldn’t not treat a diabetic, you wouldn’t not treat a patient who is hypertensive,” Simmons says. People can’t control the fact that they formed an addiction to something.
Source: https://www.npr.org/sections/health-shots/2023/03/06/1159225349/roadblock-to-suboxone-life-saving-addiction-treatment-gone
Road Block to Suboxone Life-Saving Treatment Goes Away: The U.S. Case for a Better Treatment of Substantial Drug Abuse
“That left alegacy of raising this into a higher level of scrutiny and caution, so it needs to be walked back,” Mukkamalai says. “That’s coming from education.”
The next generation of doctors, nurse practitioners, and physician assistants will have the added benefit of addiction training. The AMA and the American Society of Addiction Medicine have online resources for clinicians who want to learn on their own.
Wakeman, at Mass General Brigham, says it might be time to hold clinicians who don’t provide addiction care accountable through quality measures tied to payments.
How often a prescriber starts and continues buprenorphine treatment is a quality measure. Wakeman says that if insurers reimburse clinics for the cost of staff that aren’t traditional clinicians but are critical in addiction care, it will help.
White patients are more likely to be prescribed the medication if they have private insurance. But there are also stark differences by race at some health centers where most patients are on Medicaid and would seem to have equal access to this addiction treatment.
People are not able to remain on life-saving medication if the huge instability in housing, employment, social supports is not addressed. We fall short in that area in the United States.
Source: https://www.npr.org/sections/health-shots/2023/03/06/1159225349/roadblock-to-suboxone-life-saving-addiction-treatment-gone
Kaiser Health News: A Coproduction of NPR, WBUR, KHN and the KPhin New York Times
This story is from NPR’s partnership with WBUR and KHN. KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues.