SOCW 6443 wk 8 Discussion 1: Controversy in Psychopharmacological Intervention to Treat Substance Abuse Disorders

  

SOCW 6443 wk 8 Discussion 1: Controversy in Psychopharmacological Intervention to Treat Substance Abuse Disorders

Controversy surrounding the treatment of substance abuse disorders with other substances extends from the most basic to the philosophical. Some health care providers focus on the removal of all substances to address the addiction and argue that complete abstinence is the only real option. They believe that no medications should be given (except to save one’s life) during treatment for substance abuse. Many mental health professionals, particularly in America, hold these views. In contrast to removing all substances, others focus on the ability of the client to function. Many programs support the belief that addicts can live normal lives with controlled use of substances.

How do these opposing views in the treatment of addiction clients affect the addiction mental health practice? How does the mental health professional working with addiction prepare and support the mental health care team and the client? How do programs like the 12-step Narcotics Anonymous program compare with other approaches as far as research results?

All questions in bold then answers APA format 7th addition full references and intext citations 300 to 500 words not including the questions

For this Discussion, select a medication used in treating substance abuse disorders. Then, conduct a search for any controversy surrounding the use of this medication in treating substance abuse disorders and prepare to defend its use.

Post a description of the major actions, intended effects, and side effects of your selected medication. Explain controversy surrounding the use of this medication in treating substance abuse disorders. Defend the effective use of this medication and support your defense with evidence from the Learning

Resources

or from your personal research.

Be sure to support your postings and responses with specific references to the Learning Resources.

Resources

Lichtblau, L. (2011). Psychopharmacology demystified. Clifton Park, NY: Delmar, Cengage Learning.

Chapter 7, “Neurobiology of Addiction” (previously read in Week 2)

Preston, J. D., O’Neal, J. H., & Talaga, M. C. (2017). Handbook of clinical psychopharmacology for therapists (8th ed.). Oakland, CA: New Harbinger.

Chapter 14, “Substance-Related Disorders” (pp. 153-160)

n engl j med 370;22 nejm.org may 29, 201

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3

hensive approaches to chronic pain

into their scope of services.

Health care systems can in-
corporate nonjudgmental screen-
ing, brief intervention, and refer-
rals for further assessment and
treatment of addiction into all
clinical settings where opioids are
prescribed. Conversely, addiction-
treatment providers can screen
patients for pain, recognizing that
inadequately treated pain is a risk
factor for relapse.

Payers, including Medicare and
state Medicaid programs, can use
data-analysis tools to spot the red
flags of inappropriate prescribing
and refer prescribers to medical
boards or other state agencies for
further review, education, and
oversight. Prescription-drug mon-
itoring programs can also identi-
fy prescribers in need of assis-
tance. Coherent, evidence-based
review of clinical practice can be

conducted with the
aim of supporting
high-quality care

for both chronic pain and addic-
tion — and avoiding the unin-
tended consequence of deterring
physicians from caring for pa-
tients with complex needs.

Public and private insurers can
provide as generous coverage for
treatment of opioid-use disorder
as they do for management of
chronic pain. This standard is
infrequently met — for example,

it is long past time for Medicare
to begin covering the effective
care provided in opioid-treatment
programs.

It is also time for the FDA to
address the intertwining of chron-
ic pain and addiction farther up-
stream in the drug-development
cycle. The agency might consider
creating a pathway for develop-
ment and review of new products
and indications for simultaneous
treatment of chronic pain and
opioid-use disorder. Building on
its own work to advance the sci-
ence of abuse-deterrent formula-
tions, the FDA should also re-
quire that prescription opioids
meet basic deterrent standards
and should facilitate the gradual
reformulation of existing products
to meet such standards. In declin-
ing to apply such a standard to Zo-
hydro, the agency noted that ex-
isting deterrent mechanisms have
had minimal impact by them-
selves. However, even modest
safeguards have been shown to
reduce the potential for inappro-
priate use.5 As part of a compre-
hensive strategy, a set of reason-
able requirements for opioid
medications is well in line with
the FDA’s public health mission.
Taking such action will deter
others with less expertise from
filling a perceived void.

In the end, pointing the finger
at Zohydro is not going to resolve

the tension that exists today be-
tween chronic pain and addiction.
All concerned about the treatment
of chronic pain and all responding
to the rise in overdose deaths need
to come together to promote high-
quality and effective prevention
and treatment for both conditions.

Disclosure forms provided by the authors
are available with the full text of this article
at NEJM.org.

From the Institutes for Behavior Resources
(Y.O.) and the Maryland Department of
Health and Mental Hygiene ( J.M.S.) — both
in Baltimore.

This article was published on April 23, 2014,
at NEJM.org.

1. Public health grand rounds — prescrip-
tion drug overdoses: an American epidemic.
Atlanta: Centers for Disease Control and Pre-
vention, February 18, 2011 (http://www.cdc
.gov/about/grand-rounds/archives/2011/
01-February.htm).
2. Policy impact: prescription painkiller
overdoses. Atlanta: Centers for Disease Con-
trol and Prevention, July 2, 2013 (http://
www.cdc.gov/HomeandRecreationalSafety/
pdf/PolicyImpact-PrescriptionPainkillerOD
).
3. FDA Commissioner Margaret A. Ham-
burg statement on prescription opioid
abuse. Silver Spring, MD: Food and Drug
Administration, April 3, 2014 (http://www
.fda.gov/NewsEvents/Newsroom/
PressAnnouncements/ucm391590.htm).
4. Federation of State Medical Boards of the
United States. Pain management policies:
board by board overview. February 2014
(http://www.fsmb.org/pdf/GRPOL_Pain_
Management ).
5. Severtson SG, Bartelson BB, Davis JM, et
al. Reduced abuse, therapeutic errors, and
diversion following reformulation of extend-
ed-release oxycodone in 2010. J Pain 2013;
14:1122-30.

DOI: 10.1056/NEJMp140418

1

Copyright © 2014 Massachusetts Medical Society.

Chronic Pain, Addiction, and Zohydro

Medication-Assisted Therapies — Tackling the Opioid-
Overdose Epidemic
Nora D. Volkow, M.D., Thomas R. Frieden, M.D., M.P.H., Pamela S. Hyde, J.D., and Stephen S. Cha, M.D.

The rate of death from over-doses of prescription opioids
in the United States more than
quadrupled between 1999 and

2010 (see graph), far exceeding
the combined death toll from co-
caine and heroin overdoses.1 In
2010 alone, prescription opioids

were involved in 16,651 overdose
deaths, whereas heroin was im-
plicated in 3036. Some 82% of
the deaths due to prescription

An audio interview
with Dr. Olsen

is available at NEJM.org

P E R S P E C T I V E

n engl j med 370;22 nejm.org may 29, 20142064

opioids and 92% of those due to
heroin were classified as unin-
tentional, with the remainder be-
ing attributed predominantly to
suicide or “undetermined intent.”

Rates of emergency department
visits and substance-abuse treat-
ment admissions related to pre-
scription opioids have also in-
creased markedly. In 2007,
prescription-opioid abuse cost in-
surers an estimated $72.5 billion
— a substantial increase over
previous years.2 These health and
economic costs are similar to
those associated with other chron-
ic diseases such as asthma and
HIV infection.

These alarming trends led the
Department of Health and Hu-
man Services (HHS) to deem pre-
scription-opioid overdose deaths
an epidemic and prompted multi-
ple federal, state, and local ac-
tions.2 The HHS efforts aim to si-
multaneously reduce opioid abuse

and safeguard legitimate and
appropriate access to these med-
ications. HHS agencies are im-
plementing a coordinated, com-
prehensive effort addressing the
key risks involved in prescription-
drug abuse, particularly opioid-
related overdoses and deaths.
These efforts focus on four main
objectives: providing prescribers
with the knowledge to improve
their prescribing decisions and the
ability to identify patients’ prob-
lems related to opioid abuse, re-
ducing inappropriate access to
opioids, increasing access to effec-
tive overdose treatment, and pro-
viding substance-abuse treatment
to persons addicted to opioids.

A key driver of the overdose
epidemic is underlying substance-
use disorder. Consequently, ex-
panding access to addiction-
treatment services is an essential
component of a comprehensive
response.2 Like other chronic dis-

eases such as diabetes and hyper-
tension, addiction is generally
refractory to cure, but effective
treatment and functional recov-
ery are possible. Fortunately, cli-
nicians have three types of medi-
cation-assisted therapies (MATs)
for treating patients with opioid
addiction: methadone, buprenor-
phine, and naltrexone (see table).
Yet these medications are mark-
edly underutilized. Of the 2.5 mil-
lion Americans 12 years of age or
older who abused or were depen-
dent on opioids in 2012 (according
to the National Survey on Drug
Use and Health conducted by the
Substance Abuse and Mental
Health Services Administration
[SAMHSA]), fewer than 1 million
received MAT.

When prescribed and moni-
tored properly, MATs have proved
effective in helping patients re-
cover. Moreover, they have been
shown to be safe and cost-effec-
tive and to reduce the risk of over-
dose. A study of heroin-overdose
deaths in Baltimore between 1995
and 2009 found an association
between the increasing availabil-
ity of methadone and buprenor-
phine and an approximately 50%
decrease in the number of fatal
overdoses.3 In addition, some
MATs increase patients’ retention
in treatment, and they all improve
social functioning as well as re-
duce the risks of infectious-disease
transmission and of engagement
in criminal activities. Nevertheless,
MATs have been adopted in less
than half of private-sector treat-
ment programs, and even in pro-
grams that do offer MATs, only
34.4% of patients receive them.4

A number of barriers contrib-
ute to low access to and utilization
of MATs, including a paucity of
trained prescribers and negative
attitudes and misunderstandings

Tackling the Opioid-Overdose Epidemic

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1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

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Kilograms of opioids
sold (per 10,000)

Deaths due to opioid
overdose (per 100,000)

Admissions for opioid-abuse
treatment (per 10,000)

AUTHOR:

FIGURE:

ARTIST:

OLF:Issue date:

AUTHOR, PLEASE NOTE:
Figure has been redrawn and type has been reset.

Please check carefully.

Volkow

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5-29-14 4-23-14

Opioid Sales, Admissions for Opioid-Abuse Treatment, and Deaths Due to Opioid
Overdose in the United States, 1999–2010.

Data are from the National Vital Statistics System of the Centers for Disease Control
and Prevention, the Treatment Episode Data Set of the Substance Abuse and Mental
Health Services Administration, and the Automation of Reports and Consolidated
Orders System of the Drug Enforcement Administration.

n engl j med 370;22 nejm.org may 29, 2014

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2065

Tackling the Opioid-Overdose Epidemic

about addiction medications held
by the public, providers, and pa-
tients. For decades, a common
concern has been that MATs
merely replace one addiction with
another. Many treatment-facility
managers and staff favor an ab-
stinence model, and provider
skepticism may contribute to low
adoption of MATs.4 Systematic
prescription of inadequate doses
further reinforces the lack of
faith in MATs, since the resulting
return to opioid use perpetuates
a belief in their ineffectiveness.

Policy and regulatory barriers
are another concern. A recent re-
port from the American Society
of Addiction Medicine describing
public and private insurance cov-
erage for MATs highlights several
policy-related obstacles that war-
rant closer scrutiny. These barri-
ers include utilization-manage-
ment techniques such as limits
on dosages prescribed, annual or
lifetime medication limits, initial
authorization and reauthorization

requirements, minimal counsel-
ing coverage, and “fail first” cri-
teria requiring that other thera-
pies be attempted first (www.asam
.org/docs/advocacy/Implications
-for-Opioid-Addiction-Treatment).
Although these policies may be
intended to ensure that MAT is
the best course of treatment, they
may hinder access and appropriate
care. For example, maintenance
MAT has been shown to prevent
relapse and death but is strongly
discouraged by lifetime limits.5

In addition, although Medicaid
covers buprenorphine and metha-
done in every state, some Medic-
aid programs or their managed-
care organizations apply the
utilization-management policies
described above. Most commer-
cial insurance plans also cover
some opioid-addiction medications
— most commonly buprenorphine
— but coverage is generally lim-
ited by similar policies, and ac-
cess to care may be limited to
in-network providers. Few private

insurance plans provide coverage
for the depot injection formula-
tion of naltrexone, and most do
not cover methadone provided
through opioid treatment pro-
grams.

Implementation of the Afford-
able Care Act (ACA) will increase
access to care for many Ameri-
cans, including persons with ad-
diction. This expansion builds on
the Mental Health Parity and Ad-
diction Equity Act, which re-
quires insurance plans that offer
coverage for mental health or
substance-use disorders to pro-
vide the same level of benefits
that they do for general medical
treatment. The ACA significantly
extends the reach of the parity
law’s requirements, ensuring that
more Americans have coverage
for mental health and substance-
use disorders and that coverage
complies with the federal parity
requirements. These reforms pre-
sent new opportunities for reduc-
ing prescription-opioid abuse and

Characteristics of Medications for Opioid-Addiction Treatment.

Characteristic Methadone Buprenorphine Naltrexone

Brand names Dolophine, Methadose Subutex, Suboxone, Zubsolv Depade, ReVia, Vivitrol

Class Agonist (fully activates opioid re-
ceptors)

Partial agonist (activates opioid recep-
tors but produces a diminished re-
sponse even with full occupancy)

Antagonist (blocks the opioid receptors
and interferes with the rewarding
and analgesic effects of opioids)

Use and effects Taken once per day orally to reduce
opioid cravings and withdrawal
symptoms

Taken orally or sublingually (usually
once a day) to relieve opioid crav-
ings and withdrawal symptoms

Taken orally or by injection to diminish
the reinforcing effects of opioids
(potentially extinguishing the asso-
ciation between conditioned stimuli
and opioid use)

Advantages High strength and efficacy as long
as oral dosing (which slows brain
uptake and reduces euphoria) is
adhered to; excellent option for
patients who have no response
to other medications

Eligible to be prescribed by certified
physicians, which eliminates the
need to visit specialized treatment
clinics and thus widens availability

Not addictive or sedating and does not
result in physical dependence; a re-
cently approved depot injection for-
mulation, Vivitrol, eliminates need
for daily dosing

Disadvantages Mostly available through approved
outpatient treatment programs,
which patients must visit daily

Subutex has measurable abuse liability;
Suboxone diminishes this risk by in-
cluding naloxone, an antagonist
that induces withdrawal if the drug
is injected

Poor patient compliance (but Vivitrol
should improve compliance); initi-
ation requires attaining prolonged
(e.g., 7-day) abstinence, during
which withdrawal, relapse, and early
dropout may occur

P E R S P E C T I V E

n engl j med 370;22 nejm.org may 29, 20142066

its consequences by expanding
the number of high-risk people
who receive MATs through either
public or private insurance. The
importance of access to MATs
and other treatment services for
substance-use disorder is under-
scored by the recent recognition
of increased heroin use; what
may be less widely recognized is
that the majority of these new
heroin users initially abused pre-
scription opioids before shifting
to heroin.

HHS agencies are actively col-
laborating with public and private
stakeholders in efforts to expand
access to and improve utilization
of MATs, in tandem with other
targeted approaches to reducing
opioid overdoses.2 For example,
the National Institute on Drug
Abuse (NIDA) is funding research
to improve delivery of MATs to
vulnerable populations, includ-
ing those in the criminal justice
system. NIDA is also working to
develop new pharmacologic treat-
ments for opioid addiction and
helping to fund “user friendly”
delivery systems for naloxone (i.e.,
intranasal rather than injection).
SAMHSA is encouraging MAT
use in its state funding of sub-
stance-abuse treatment programs
through the Substance Abuse
Prevention and Treatment Block
Grant and regulatory oversight of
methadone and buprenorphine for
opioid addiction. Furthermore,

SAMHSA supports production
and dissemination of educational
resources to MAT prescribers, as
well as an “Opioid Overdose Tool-
kit” to educate first responders,
treatment providers, and patients
about ways to prevent and inter-
vene in opioid-overdose cases.

The Centers for Disease Con-
trol and Prevention is working to
empower states to implement com-
prehensive strategies, including
MATs, for preventing prescrip-
tion-drug overdoses. These strat-

egies focus primarily on address-
ing the overdose epidemic through
enhanced surveillance, effective
policies, and clinical practices that
establish statewide prescribing
norms. Such efforts can be en-
hanced by using data sources to
identify and intervene in cases of
patients or providers who fall out-
side those norms. And the Centers
for Medicare and Medicaid Ser-
vices is working to enhance access
to MATs by Medicaid programs
through improved benefit design
and application of the Mental
Health Parity and Addiction Equi-
ty Act. But to be successful, all
these initiatives require the active
engagement and participation of
the medical community.

The epidemic of prescription-
opioid overdose is complex. Ex-
panding access to MATs is a
crucial component of the effort
to help patients recover. It is also
necessary, however, to implement

primary prevention policies that
curb the inappropriate prescrib-
ing of opioid analgesics — the
key upstream driver of the epi-
demic — while avoiding jeopar-
dizing critical or even lifesaving
opioid treatment when it is need-
ed. Essential steps for physicians
will be to reduce unnecessary
or excessive opioid prescribing,
routinely check data from pre-
scription-drug–monitoring pro-
grams to identify patients who
may be misusing opioids, and
take full advantage of effective
MATs for people with opioid ad-
diction.

Disclosure forms provided by the au-
thors are available with the full text of this
article at NEJM.org.

From the National Institute on Drug Abuse,
National Institutes of Health, Bethesda
(N.D.V.), the Substance Abuse and Mental
Health Services Administration, Rockville
(P.S.H.), and the Center for Medicaid and
CHIP Services, Centers for Medicare and
Medicaid Services, Baltimore (S.S.C.) — all
in Maryland; and the Centers for Disease
Control and Prevention, Atlanta (T.R.F.).

This article was published on April 23, 2014,
and updated on May 1, 2014, at NEJM.org.

1. Jones CM, Mack KA, Paulozzi LJ. Pharma-
ceutical overdose deaths, United States,
2010. JAMA 2013;309:657-9.
2. Addressing prescription drug abuse in the
United States: current activities and future
opportunities. Atlanta: Centers for Disease
Control and Prevention, 2013 (http://www
.cdc.gov/homeandrecreationalsafety/
overdose/hhs_rx_abuse.html).
3. Schwartz RP, Gryczynski J, O’Grady KE,
et al. Opioid agonist treatments and heroin
overdose deaths in Baltimore, Maryland,
1995-2009. Am J Public Health 2013;103:917-
22.
4. Knudsen HK, Abraham AJ, Roman PM.
Adoption and implementation of medica-
tions in addiction treatment programs. J Ad-
dict Med 2011;5:21-7.
5. Clark RE, Baxter JD. Responses of state
Medicaid programs to buprenorphine diver-
sion: doing more harm than good? JAMA In-
tern Med 2013;173:1571-2.

DOI: 10.1056/NEJMp1402780
Copyright © 2014 Massachusetts Medical Society.

Tackling the Opioid-Overdose Epidemic

A key driver of the overdose epidemic is
underlying substance-use disorder.
Consequently, expanding access to

addiction-treatment services is an essential
component of a comprehensive response.

Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.