What Science Says about Opioid Use Disorder and Its Treatment Perilou Goddard, Ph.D. Department of Psychological Science Northern Kentucky University Examples of Opioids Agonists (activate opioid receptors) Heroin Fentanyl Morphine OxyContin, Percocet (oxycodone) Vicodin (hydrocodone) Codeine Buprenorphine (Suboxone, Buprenex, Probuphine) Methadone Endorphins Antagonists (block opioid receptors) Narcan (naloxone), Vivitrol (naltrexone) What Is Heroin? Binds to opioid receptors in the brain Causes intense feeling of well-being, reduces pain Usually injected, but can be snorted or smoked if pure enough Produces tolerance with regular use Has short half-life, causes very painful withdrawal symptoms NOT universally addicting 1
This Is Your Brain This Is Your Brain Frontal Cortex Limbic System Limbic System: GO! Dopamine sends signals in the limbic system This Is Your Brain This Is Your Brain Frontal Lobes: STOP and THINK FIRST! Endorphins: Your body s natural trigger for dopamine Limbic System: GO! 2
This Is Your Brain on Opioids This Is Your Brain on Opioids Frontal Lobes: STOP and THINK FIRST! Limbic System: GO! Drugs cause dopamine to flood the limbic system Limbic System: GO! This Is Your Brain on Opioids Is Opioid Use Disorder a Disease? What about the initial decision to use heroin or other opioids in the first place? Doesn t THAT make opioid use disorder a choice instead of a disease? Individual behavior does play a role initially But even that apparent choice is not entirely under the person s control 3
Is Opioid Use Disorder a Disease? What Science Says Many of the risk factors for addiction are not within the individual s control Genetics: 50% of the risk for addiction Early environment: Adverse Childhood Experiences (ACEs) prior to age 18 Physical, emotional, or sexual abuse Physical or emotional neglect Loss of parent through death, divorce, or incarceration Mental illness or substance use disorder in parent Witnessing domestic violence Dose-response relationship: More ACEs = Greater risk of addiction Is Opioid Use Disorder a Disease? What Science Says Other risk factors for OUD that are not within the individual s control Adolescent brain development Competing sources of pleasure/satisfaction Availability of particular drugs in one s environment What Science Says: Yes, OUD Is a Disease It s a chronic disease that s analogous in many ways to Type 2 diabetes Personal choice plays a role initially Even then, the choice is strongly influenced by many factors outside the individual s control, so it s not as free as it appears Once the disease develops, permanent physical changes have often already taken place Lifestyle changes/just saying NO are often not enough Medication is usually necessary, at least at first Some individuals will need medication for a lifetime Not typically cured, but functional recovery is possible Responding to Opioid Use Disorder: What s Less Effective Fear campaigns and Just Say No Detoxification alone 12-Step programs by themselves Abstinence-only rehabilitation IOP, short-term or long-term inpatient treatment Even Hazelden/Betty Ford Center ultimately abandoned abstinence-only treatment for opioid use disorder Recovery Kentucky s 15 centers 4
Responding to Opioid Use Disorder: What s Less Effective Only 43% of initial program entrants make it to Phase I and agree to be followed up Nearly 22% of those eligible for follow-up were disqualified for being incarcerated Evidence-Based Treatment Nationwide, only about 20% of people with opioid use disorder receive treatment, and that s any treatment (not necessarily the most effective treatment) Wait times for many services in Northern Kentucky range from 1 week to 9 months This can be a literal death sentence The most effective treatment for opioid use disorder is the combination of medications and behavioral therapy Should be tailored to each individual s needs Not one size fits all Three medications are currently available Vivitrol Buprenorphine (Suboxone) Methadone : Vivitrol Long-acting injectable form of opioid antagonist naltrexone Blocks the effects of opioid drugs the high is reduced or eliminated if heroin is used Reduces cravings for heroin, making it easier to benefit from behavioral therapy Can be prescribed by anyone licensed to prescribe meds (physicians, physician s assistants, nurse practitioners) 5
Vivitrol Very expensive (up to $1500/injection) Must detox from heroin and other opioids for 5-10 days prior to getting Vivitrol May help after incarceration or drug-free rehabilitation treatment Must be repeated every 4 weeks Much less research on Vivitrol than other forms of MAT : Suboxone Combination of buprenorphine (a partial opioid agonist) and naloxone (an opioid antagonist) taken once a day (long half-life) Helps people stop using heroin without causing them to have withdrawal symptoms Naloxone is an abuse deterrent Suboxone Over 20 years of research show Suboxone s main ingredient is an effective treatment for heroin addiction Can be prescribed by physicians in an office setting, but MDs are limited in how many Suboxone patients they can have Needs to be combined with psychosocial services : Methadone Over 40 years of research shows that methadone maintenance therapy is the most effective treatment for heroin addiction Methadone is a full opioid agonist taken once a day (long half-life) with stable dosing, doesn t produce a high or intoxication blocks the high from heroin relieves heroin craving prevents withdrawal symptoms 6
Methadone Benefits of methadone maintenance very significant increases in treatment retention significant reductions in heroin and other opioid use, injecting drug use, overdose, blood-borne diseases, criminal activity, and mortality significant improvements in family stability and employment big economic benefits ($4-5 return on investment for every $1 invested) Effective Methadone Programs Key principles: Individually tailored dosing with no arbitrarily low limits No arbitrary time limit Combination of methadone and evidence-based counseling tailored to individuals needs In other countries, methadone programs are often more flexible and less regulated British system with multiple tiers of supervised use Primary care physicians administer methadone and buprenorphine in most other developed countries Progress in MAT is increasingly available Programs in some jails give some people a shot of Vivitrol before they are released, with follow-up post-release St. E s has adopted a Suboxone program from Hazelden/Betty Ford Center U.S. Office of National Drug Control Policy is advocating for MAT Substance Abuse and Mental Health Services Administration (SAMHSA, a major source of federal grant money for drug programs) has banned drug courts that receive federal funding from requiring participants to cease MAT to be eligible Controversies regarding MAT is just substituting one addiction for another This confuses physical dependence and addiction People receiving methadone or Suboxone treatment are physically dependent This just means their bodies have adapted to the type and amount of medication they re receiving They would experience withdrawal symptoms if they suddenly stopped taking their meds The same thing would happen to chronic pain patients who are taking their opioid pain medications exactly as directed Physical dependence is a normal consequence of repeated opioid use and can be reversed by slowly tapering the dose of the medication 7
Controversies regarding Addiction is not the same as physical dependence Key criteria for addiction Powerful, even uncontrollable, cravings Cravings are rooted in altered brain biology (as discussed earlier) Difficulty controlling one s drug use despite persistent desire or efforts to do so Drug use despite overtly harmful consequences (e.g., serious physical problems caused or exacerbated by the drug use, or interference with major role obligations) Controversies regarding MAT recovery isn t real recovery This belief is perpetuated by many U.S. recovery programs and 12-Step groups Narcotics Anonymous governing rules allow individual NA chapters to decide whether people in MAT can speak at meetings This belief contributes to the stigma surrounding MAT Controversies regarding SAMHSA defines recovery as the experience (a process and a sustained status) through which individuals... utilize internal and external resources to voluntarily resolve severe drug problems, heal the wounds inflicted by these problems, actively manage their continued vulnerability to such problems, and develop a healthy, productive, and meaningful life (White, 2007, p. 236) Language Affects Stigma Another consideration is how we talk about substance use Several leaders in the field, including the Director Botticelli of the U.S. Office of Drug Control Policy, have called for change Person first language is already standard in discussing people with disabilities and is gaining ground in other medical contexts Person with schizophrenia is used instead of schizophrenic 8
Examples: Language Affects Stigma Person who uses heroin instead of Heroin user Person with a heroin use disorder instead of Heroin addict Heroin use disorder instead of Heroin addiction Person in long-term recovery instead of former addict Urine screen that s negative [or positive] for illicit drugs instead of Clean [or dirty] urine screen My former student Sara Sharpe and I have empirical evidence that lower levels of stigma toward people who use heroin and higher levels of support for MAT are associated with less stigmatizing language Questions? Comments? goddard@nku.edu 9