By Coverys Risk Management
Opioid addiction has become epidemic, but stigma can undermine treatment and recovery. Effective treatment requires a better understanding of addiction and its social impact, as well as a reduction of implicit bias and the implementation of risk management strategies. Modern treatments typically combine medication with therapy.
The Opioid Crisis
The opioid crisis can be broken down into distinct waves
. The first wave occurred in the late 1990s and early 2000s, when many people became addicted to prescription opioids. Another wave arrived in 2010 when Mexican drug cartels brought black tar heroin into the U.S.
The third wave is happening now. According to the CDC
, fentanyl is a synthetic opioid that is 50 times stronger than heroin. It is frequently mixed with other recreational and prescription drugs – including heroin, cocaine, and methamphetamine – and made into pills that look like other prescription opioids.
Data from the CDC
shows that more than 107,000 people died of drug overdoses in 2021, and roughly two-thirds of these deaths involved fentanyl or similar synthetic opioids. Drug overdoses are the leading cause of death for people between the ages of 18 and 45.
Scientists understand that addiction is a brain disorder, not a character flaw as it has been described through the public lens. Treatment is more helpful than punishment. According to the Substance Abuse and Mental Health Services Administration
(SAMHSA), more than 20 million adults deal with substance use disorder. Addiction is a chronic but treatable medical condition.
Diagnosing and Treating Addiction
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) defines opioid use disorder as “a problematic pattern of opioid use leading to clinically significant impairment or distress.” There are 11 criteria, and two or more must be present within the last 12 months for a diagnosis.
When addiction is diagnosed, treatment can come in the form of medications or psychosocial therapy. According to The Pew Charitable Trusts
, a combination of medication and psychosocial therapy has the best outcome.
There are several medication treatment options, according to SAMHSA
- Buprenorphine can diminish the effects of physical dependency, including withdrawal and craving. It can also increase safety in cases of overdose and lower the potential for misuse. Several buprenorphine products have received FDA approval, including Suboxone, Subutex, and Sublocade.
- Methadone is another medication used to treat opioid use disorder and can also help with pain management.
- Naltrexone is used to treat opioid use disorder as well as alcohol use disorder. It works by blocking the euphoric and sedative effects of opioids.
When someone is using drugs, interventions can help reduce harm. These interventions can be medical or societal in nature and include the following:
- Naloxone, which the National Institute on Drug Abuse says can rapidly reverse an opioid overdose.
- 911 Good Samaritan laws, which help people seek medical help without risking drug charges.
- Fentanyl test strips, which are used to identify drugs that have been laced with fentanyl.
- Syringe access and exchange programs.
Regulations and Compliance
Opioid treatment programs that use medication-assisted treatment are governed by the Certification of Opioid Treatment Programs, 42 Code of Federal Regulations. According to SAMHSA
, these programs must be certified and accredited, licensed in the state they operate in, and registered with the Drug Enforcement Administration. Additionally, having access to counseling and behavioral therapies is recommended for patients receiving medication.
The medications themselves are also subject to regulation.
- Buprenorphine is classified as a Schedule III controlled substance. A buprenorphine waiver certification is needed to administer, dispense, or prescribe buprenorphine. According to SAMHSA, there is an alternative Notification of Intent for qualified practitioners treating up to 30 patients; otherwise, training for physicians takes eight hours and training for nurses or physician assistants takes 24 hours.
- Methadone is classified as a Schedule II controlled substance, and it should be taken under the supervision of a practitioner, although use at home may be permitted after a period of stability.
- Naltrexone can only be administered if patient has been opioid-free for a week prior. Patients who continue to use opioids risk accidental overdose.
Healthcare providers treating substance use disorders are also subject to confidentiality rules under 42 CFR Part 2
. Before information can be released, appropriate consent must be obtained.
Five Steps of Addiction Management
As always, there should be a written description of the program that includes the purpose, guidelines, patient selection criteria, evidence-based processes, and compliance measurement methods. There are generally five steps of addiction management:
- Well defined treatment plans. Plans should be supported by documentation that includes a comprehensive intake of the patient’s condition, method of use, for how long, and any treatments used previously.
- Patient focus. Addiction medicine should be tailored to the response of the patient and therapy must be continuously adjusted to meet evolving patient needs.
- Precautionary monitoring. Patients are seen frequently in the beginning of treatment – usually on a weekly basis, slowly progressing to monthly check-ins over time. The practitioner should monitor the patient’s response and compliance to treatment through routine and random drug testing and pill/film counts.
- Ongoing management. Patients should check in regularly and make the practitioner aware of any upcoming procedures that require the use of narcotics.
- Ancillary services. Behavioral and cognitive therapies and peer support groups should be identified, although they are not an absolute requirement of treatment.
A successful addiction medicine practice relies heavily on the tools and resources available. Best practices mirror the recommendations for responsible opioid prescribing and include:
This article was, in part, based on the Coverys presentation “Addiction Medicine: Supporting Healthcare to Empower Recovery,” presented by Tricia Brooks-Phillips, RN, MSN, CPHRM; and Sara Meyer, PharmD, BCPS.
Copyrighted. No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.
- Prescription drug monitoring program. Query the states’ prescription drug monitoring program to validate compliance and to verify that the patient has not been prescribed other controlled substances.
- Trust but verify compliance. Practitioners must trust the patient and build the therapeutic relationship, while also verifying compliance through random urine drug testing and random pill or film counts.
- Electronic prescribing. Electronically prescribing Buprenorphine can reduce the likelihood of diversion.
- EMR tools. If possible, the electronic medical record (EMR) should have templates to help the practitioner capture all the elements of an addiction medicine visit, including suicide assessment, response to therapy/craving screening, prompts for confirmatory testing, state prescription monitoring program data, and notes about any social stressors.