As the nation struggles with the heartbreaking reality that the opioid crisis has reached epidemic proportions, the search for effective treatment of opioid use disorders (OUD) has been identified as a national priority.
Angelo McClain, PhD, LICSW
NASW Chief Executive Officer
Social workers are at the forefront in the fight to reduce the rates of individual disability associated with OUD and the escalating rates of accidental opioid overdose deaths.
Health and human service organizations are increasingly turning to evidence-based treatments such as medication-assisted treatment (MAT).
Medications such as methadone and buprenorphine are consistently effective in treating OUD. Increasingly, use of these medications — in combination with psychosocial interventions — is proving critical to stemming the tide of this devastating epidemic.
Although MAT is one of the most effective treatments for OUD, it is widely misunderstood. Understanding the roots of opioid addiction and treatment is important because attitudes and beliefs about opioid use and addiction over the past 150 years continue to influence policies governing MAT.
During the late 19th and early 20th centuries, U.S. society generally viewed opiate addiction as socially irresponsible and immoral behavior, stemming from weak will, lack of morals, or other psychodynamic factors, or a predilection that could be corrected by measures promoting abstinence and through criminalization of uncontrolled use and distribution.
These views had a profound effect on the societal response to opioid use and addiction in the 20th century, and these attitudes persist today.
Social workers must be leaders in shifting societal and political attitudes toward an understanding that opioid addiction is a disease that requires comprehensive long-term maintenance with medication and psychosocial interventions.
Social work also must play a leading role in fueling the trend toward greater use and acceptance of MAT. Despite evidence of MAT’s effectiveness, traditional treatment providers still resist the integration of MAT into addiction treatment.
The FDA has approved three medications for use in the treatment of OUD: methadone, buprenorphine and naltrexone. The FDA approves maintenance of opioid addiction treatment with these medications when used in conjunction with psychosocial and medical services. All three medications show improved retention in treatment.
The evidence for efficacy both in reducing opioid use and retaining patients in care is strongest for methadone maintenance, which remains the gold standard of care for OUD.
Methadone, the most widely used replacement for heroin, is a synthetic opioid that mitigates opioid withdrawal symptoms and, at higher doses, blocks the effects of heroin and other drugs containing opiates. It has been used successfully for more than 40 years in medically supported maintenance or detoxification programs.
Methadone has been shown to eliminate withdrawal symptoms produced by stopping the use of heroin and prescription opiate medications, because it acts on the same targets in the brain as those drugs.
Methadone can be dispensed only at an outpatient opioid treatment program certified by SAMHSA and registered with the Drug Enforcement Administration or to a hospitalized patient in an emergency. SAMHSA-certified OTP facilities provide daily doses until the patient is deemed stable enough to receive take-home doses.
Buprenorphine, approved by the FDA in 2002 to treat opioid dependence, is a partial opioid agonist that suppresses withdrawal symptoms. Although buprenorphine can produce opioid agonist effects and side effects, such as euphoria and respiratory depression, its maximal effects are generally milder than those of full agonists like heroin and methadone.
Physicians are permitted to distribute buprenorphine at intensive outpatient treatment programs that are authorized to provide methadone. Additionally, a special program has been set up so that buprenorphine can be prescribed by physicians in office settings and dispensed by pharmacists.
Naltrexone, marketed under the brand name Vivitrol®, is a nonaddictive antagonist used in the treatment of opioid dependence. The medication blocks opioid receptors so they cannot be activated. This “blockade” action, combined with naltrexone’s ability to bind to opioid receptors even in the presence of other opioids, helps keep abused drugs from exerting their effects when patients have taken naltrexone.
Naltrexone does not mimic the effects of opioids; it simply blocks opioid receptor sites so that other substances present in a patient’s system cannot bind to them.
Naltrexone is administered in an injectable long-acting formula designed for once-monthly dosing. The FDA recommends that Naltrexone should be used only in patients who have been detoxified from opioids and have been opioid free for seven to 10 days.
Research shows that MAT significantly augments treatment retention, reduces illicit opioid use, reduces the burden of opioid craving, and provides effective relief of the opioid withdrawal syndrome. MAT is a stabilizing addition to relapse-prevention counseling in that it increases the effectiveness of those interventions.
Social workers must learn about available medicines and promote policies that ensure MAT is part of a comprehensive approach to treating OUD.
Visit the SAMHSA website to learn more.
Contact Angelo McClain at NASWCEO@socialworkers.org.