In 2015, there were between 92,000 and 170,000 Ohioans abusing or dependent upon opioids, resulting in annual costs associated with treatment, criminal justice, and lost productivity of $2.8 billion to $5 billion.
But what are their options for recovery?
A recent study at Ohio State University found, that in the best-case scenario, Ohio has the capacity to treat only 20 percent to 40 percent of the population dependent upon opioids. The same study found distinct geographic disparities in access to treatment: Many people in rural areas of Ohio have extremely limited access to medication-assisted treatment.
Nationally, in 2015, only 11 percent of people who needed substance use treatment received it. A recent study estimated that the U.S. was short 1.3 million treatment slots for medication-assisted treatment in 2012 — and demand has only increased since then.
That means when someone is ready and willing to seek help, often the help simply isn’t available or accessible. Treatment is complicated by society’s negative attitudes — including the attitudes of law enforcement officers, physicians, and other health care practitioners — toward substance users.
Risk is real
If you take any opioid for pain relief, you could get hooked and not even know it. Tolerance can develop after even a few days of continued opioid use. There is no one-size-fits-all opioid substance use treatment strategy, and everyone’s path to recovery is different. But for any treatment to work, it must include ongoing counseling and support. And there are multiple prongs: medical services, educational services, family services, vocational services, mental health services and continuing care.
Treatment strategies include detoxification (stopping the drug), substitution (substituting another drug and gradually reducing its dose), and maintenance (substituting another drug that is taken indefinitely).
There are several approaches to detoxification: stopping the opioid and allowing withdrawal to run its course (cold turkey); substituting a similar but less potent drug, then gradually decreasing the dose and stopping the drug.
In both detoxification strategies, treatment is usually needed to lessen the symptoms of withdrawal. Substitution typically involves giving drugs such as methadone and buprenorphine, which are then slowly decreased and eventually stopped completely. Detoxification is just the first step toward recovery, and must be followed by rehabilitation to prevent a return to opioid use. Ongoing treatment may include long-term counseling and support and drugs such as naltrexone.
For people who continually return to using opioids, another approach — maintenance — is often preferred. It involves substituting a prescribed drug that the user takes for a long time (months or years). Methadone, buprenorphine, or naltrexone may be used as substitutes for opioids.
Maintaining opioid users with regular doses of one of these drugs enables them to be socially productive because they do not have to spend time getting the illicit opioid and because the drugs used do not interfere with functioning the way that illicit drug use does. For some opioid users, the treatment works. For many, lifelong maintenance is necessary.
Methadone suppresses withdrawal symptoms, however, opioid users must appear once a day at a clinic where methadone is dispensed. For many, such programs work. However, because the participants continue to take an opioid, many people in society disapprove of these programs. Ohio has only 26 certified methadone treatment centers.
Buprenorphine is being used more and more because it can be prescribed by doctors in their office. Thus, opioid users do not have to go to a special clinic. But training required to qualify for a waiver to prescribe the drug. In Ohio, there are 377 doctors who are certified to prescribe buprenorphine.
“It has been estimated that for every dollar spent on methadone and buprenorphine treatment, $1.80 in social savings would be realized,” says Mike Betz, assistant professor in Ohio State’s Department of Human Sciences.
Naltrexone is a drug that blocks the effects of opioids (opioid antagonist). Before starting naltrexone, people must be fully detoxified from opioids, or a severe withdrawal reaction can occur.
Depending on the dose, naltrexone’s effects last from 24 to 72 hours. Thus, the drug can be taken once a day or as few as three times a week. Because this drug has no opioid effects, this drug is most useful for opioid users who are strongly motivated to remain free of opioids and who are not severely dependent on opioids.
There are also new vaccines under development that target opioids in the bloodstream and block them from reaching the brain.
Regardless of which approach is used, ongoing counseling and support is essential. Support may include specially trained doctors, nurses, counselors, opioid maintenance programs, family members, friends, and other people with the same substance use disorder (support groups).
In the therapeutic community concept, opioid users live in a communal, residential center for an extended period of time. These programs help people build new lives through training, education, and redirection. The programs have helped many people, but initial dropout rates are high. Questions about precisely how well these programs have worked and how widely they should be applied remain unanswered. Because these programs require a lot of resources to run, many people may be unable to afford them.
Cultural and social factors are very important in initiating and maintaining (or relapsing to) substance use. People who are trying to stop using a substance find it much more difficult if they are around others who also use that substance.
They need to remove themselves from those triggers.
(Some of this information was adapted from material written by Gerald F. O’Malley, DO, Professor of Emergency Medicine, Sidney Kimmel School of Medicine, Thomas Jefferson University and Hospital; and Rika O’Malley, MD, Attending Physician, Department of Emergency Medicine, Einstein Medical Center.)