How to Solve the Opioid Crisis, Cheap

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How to Solve the Opioid Crisis, Cheap

By Kenneth Anderson 01/19/17

The Case for Pharmacy Dosing of Methadone

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How to Solve the Opioid Crisis, Cheap
Prescribing methadone could solve the opioid crisis.

The stigma around methadone use and the several important problems endemic to the system of methadone clinics in the United States are well-known, reducing the number of users who can benefit from the life-saving medication. These issues are important reasons why the promulgation of other forms of Medication-Assisted Treatment has been so important. At the same time, other countries have found great success in combating their own opioid crises through innovations in the way that methadone is prescribed, dispensed and viewed by the larger cultures. Kenneth Anderson highlights critical and important differences between U.S. methadone policy and those in other countries, and argues that there is a quick and inexpensive way to address our opioid problem….Richard Juman, PsyD

The first question we should be asking ourselves if we want to solve the opioid crisis in the U.S. is this: are there any countries in the world that have been confronted by and went on to solve as big an opioid crisis as the U.S. currently has? The answer is yes. There are many countries in the world which had huge opioid problems, equal in magnitude to the current U.S. problem, which solved those problems and reduced overdose deaths and the number of new heroin users to almost nothing. Let's look at Switzerland as an example.

From 1995 to 2012 Switzerland saw a 72% reduction in drug related deaths. These deaths were primarily due to heroin overdose. The death rates plummeted from 5.34 per 100,000 in 1995 to 1.51 per 100,000 in 2012. Meanwhile, in the U.S., drug related deaths have skyrocketed. Data extracted from CDC WONDER shows that between 1999 and 2015, U.S. heroin overdose deaths increased 471%, going from a rate of 0.7 deaths per 100,000 in 1995 to 4.0 per 100,000 in 2015. U.S. overdose deaths due to any opioid (prescription opioid or heroin) rose 416%, going from 1.9 deaths per 100,000 in 1995 to 9.8 per 100,000 in 2015. The percentage of young people who have ever used heroin has also plummeted in Switzerland. Between 1992 and 2012 there was a 92% reduction in young people (age 15 to 24) who had ever used heroin. This fell from 1.3% in 1992 to 0.1% in 2012. Meanwhile, according to the NSDUH, in the U.S. the number of young people who had ever used heroin increased 50% from 1.0% in 1992 to 1.5% in 2014. Why is Switzerland succeeding so well while the U.S. is failing miserably?

Methadone clinics are a ridiculously expensive way to deliver a ridiculously cheap drug.

The overwhelming difference is that in Switzerland, methadone is free and extremely easy to access. Swiss methadone maintenance patients can get their prescription from their general practitioner and they can dose at a local pharmacy instead of going to a methadone clinic. Because of this, there are no waiting lists for methadone maintenance treatment, there is no shame or stigma or traveling hundreds of miles to get to a clinic, and the extremely low cost is covered entirely by national health insurance for everyone. In contrast, in the U.S. many methadone maintenance patients must pay huge fees out of pocket, which they cannot afford.

When methadone is properly prescribed, with adequate doses and no barriers to access, it is proven to reduce deaths among heroin users by 75%. However, in the U.S. it is rarely, if ever, properly prescribed, because the clinic system itself creates such barriers to access that people drop out of the programs. Methadone should never be "liquid handcuffs."

One of the main reasons why all of this is so important is that Medication-Assisted Treatment (MAT), with methadone or buprenorphine, is by far the safest path in the treatment of opioid dependence. The alternative—a program of care that involves detoxing a client to abstinence without initiating MAT—increases the odds of dying of a heroin overdose about 3,000% over continuing to use heroin and getting no treatment at all. The reason is that such clients’ tolerance is so low compared to their previous level while actively using, that an overdose becomes much more likely. So getting a client into a decent medication-assisted treatment program is the best way to see that he or she lives and recovers. But the best programs are not found in the U.S., but only in foreign countries like Switzerland, where pharmacy dosing is available.

In Switzerland, methadone is covered 100% by national health insurance, and all barriers to access have been minimized (Federal Office of Public Health [FOPH], 2013). General practitioners can prescribe methadone maintenance as part of their office practice, so instead of going to a specialized methadone clinic, people can go and dose at the local drug store. There are no hoops to jump through to get methadone in Switzerland, no 12-step meeting attendance is required, and people are not kicked off methadone for dirty urine samples. No one has to travel hundreds of miles or spend hundreds of dollars out of pocket to get methadone; it is all covered by national health insurance and is as close as the nearest pharmacy. Among Swiss patients receiving medication-assisted treatment in 2014, about 85% received methadone, 8% received heroin-assisted treatment, and 7% received some other drug such as buprenorphine, Vivitrol, or slow-release morphine. Moreover, nearly everyone in treatment for heroin dependence in Switzerland gets opioid substitution therapy, even if they opt for psychosocial treatment as well.

That’s because there is no institutional stigma attached to opioid substitution therapy in Switzerland. Here is what the Swiss guidelines (FOPH, 2013) have to say about urine testing: "Patients should be asked about their parallel consumption of other substances. Provided there is no threat of sanctions, their replies are generally reliable. Systematic urine testing does not yield any further benefit in such cases." The guidelines have this to say about take-home doses: "Stable patients can be provided with take-away doses with the specific aim of strengthening the relationship of trust and improving the success of treatment (less parallel consumption, higher retention rate)."

Currently there are about 22,000 individuals with heroin dependence in Switzerland and roughly 85% are receiving medication-assisted treatment. That’s a far cry from the situation in the U.S., where only 27% of those admitted for heroin dependence receive any sort of medication-assisted treatment—and all too often this is opioid detox, which again increases overdose risk rather than maintenance.

But isn't going on methadone maintenance just trading one addiction for another? Absolutely not. Substance Use Disorder is defined by the DSM as substance use which interferes with your life in terms of some very specific criteria. People who are stabilized on methadone function normally and can have jobs and families just like people with diabetes stabilized on insulin can. People who are stabilized on methadone and are not engaged in problematic use with other drugs meet none of the DSM criteria for substance use disorder. The idea that people on methadone maintenance are somehow addicted is a myth spread by 12-step groups like Narcotics Anonymous who have an official policy of discrimination against methadone clients. Methadone itself is extremely cheap; it is an old generic medicine that costs little to manufacture, and the cost is less than a dollar per day even for those on a high dose. Much of the cost for methadone clinics go to pay for the clinic environment itself, which would be significantly reduced were methadone available in pharmacies, decreasing the cost which is a barrier to treatment for many. On top of this, insurance coverage for methadone in the U.S. is complete chaos. Some insurance plans cover it and some don't. Some states cover it under Medicaid and some don't. And some clinics refuse insurance and accept only cash. Some people are being charged around $400 a month, which they cannot afford. This is just one more reason why pharmacy and office-based dosing is essential.

Between CARA (the Comprehensive Addiction and Recovery Act), the National Drug Control Strategy, and the 21st Century Cures Act, there is a plan underway to expand access to buprenorphine, and some people are calling for doubling the number of methadone clinics. These are good things, but they are not enough. Buprenorphine is expensive. Methadone clinics are a ridiculously expensive way to deliver a ridiculously cheap drug. Not only does it cost huge amounts of money to build and staff methadone clinics, neighborhoods fight against them and clients feel shamed and stigmatized by walking through their doors. Once inside, clients are often forced to undergo confrontational "treatments" that were debunked ages ago. Not only that, but many methadone clients have to pay huge fees out of pocket for this. If one could simply walk into the neighborhood drug store, dose, then go to work, the stigma would disappear, as would the NIMBY (Not In My Back Yard) objections of the neighborhood. And the cost would go down to next to nothing.

You might be thinking Switzerland is just a fluke, and that office-based prescribing and pharmacy-based dosing won't work anywhere else. You would be wrong. These practices are used all over Europe and Australia. In Australia, over 70% of methadone clients dose at the pharmacy and, if one excludes those receiving methadone in prison, the number is closer to 80%. The rate of accidental opioid overdose death in Australia (age 15-54) has dropped 56% from a peak of 10.19 deaths per 100,000 in 1999 to 4.47 in 2012. In Germany, drug overdose deaths dropped 51% from a peak of 2,125 deaths in 1991 to 1,032 deaths in 2014. In Germany, about 90% of opioid substitution patients receive their medication from doctors in independent medical practice; only about 10% are enrolled in methadone clinics. If we wish to cut U.S. opioid overdose deaths by the same amounts we see in Europe and Australia, then all that is required is the passage of one single simple law to allow office-based prescription of methadone maintenance and to allow clients to dose in the drug store or the doctor's office... Congress could pass the law tomorrow and cut opioid deaths by at least half. So why don't they?

The simplest and cheapest thing we can do to reverse the opioid crisis is to follow the example of Switzerland, Germany, Australia, and other countries that have already taken this step.

Kenneth Anderson is the founder and CEO of HAMS: Harm Reduction for Alcohol and the author of How to Change Your Drinking: A Harm Reduction Guide to Alcohol. He is a regular presenter at the National Harm Reduction Conference and is currently pursuing a PhD in addiction psychology.

References

Federal Office of Public Health. (2013). Substitution-assisted treatment in opioid dependence. FOPH publication number: Dir 11.13 1500 d 1000 f 300 i 200 e 20EXT13XX. Berne, Switzerland.

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