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Hayley: You’re listening to Straight Talk With The Doc, a podcast on mental health, addiction, and treatment. My name is Hayley and I’m here with addiction medicine specialist, Dr. Bhatt. How are you doing?
Dr. Bhatt: I’m good Hayley. How are you?
Hayley: I’m great and I’m excited to get into today’s topic. The opioid epidemic is still a hot topic as people are still dying every day from an opioid overdose. In past episodes, we’ve gotten into the history of the opioid epidemic. And in another one we talked about medication assisted treatment. But there’s a group of medications that are specifically used to help people with an opioid addiction. Although these can be great in terms of helping someone get off a drug that could potentially kill them, there is some concern that one addiction is just being replaced with another. But before we get into that, Dr. Bhatt, can you just tell me about the medication options that are used to treat an opioid use disorder?
Dr. Bhatt: When we’ve talked about opioid use disorders in the past and previous segments, like you mentioned, we’ve emphasized how we’ve gotten here and what are the variables that have been involved in why we’ve had such a robust opioid use disorder problem. I think when people talk about what can we do about it, there’s been a multitude of things that I think people have tried to put in place. And medications have been one that’s been quite controversial. Medications that exist for opioid use disorders have been around for a little while, especially those like methadone which is quite prevalent in helping those individuals who suffer from heroin or other opioid use disorders. Basically, methadone is one that can help someone get off illicit substance use but replace it with a prescribed medication to help them have significant harm reduction. Then there’s another medication out there called naltrexone which is an opposite type of medication. It’s actually an opioid blocker and that’s helped to reduce cravings and keep people abstinent from using illicit substances. One of the newer medications that’s been being used, and I say newer even though it’s been around for quite a while, is buprenorphine. And that’s kind of a mixed receptor blocker and receptor activator that works similar to methadone in a way, where it can help somebody stay abstinent from illicit substances, decrease cravings, and actually help and is used often in detoxification processes. Just like methadone. Those are three of the more common FDA approved medications for opioid use disorders.
Hayley: You said buprenorphine is a mixture. Can you explain how that works and how it helps people?
Dr. Bhatt: When we talk about agonist and antagonist medications, basically they talk about how they can activate or block a certain receptor site. When we talk about opioids, they work on a certain opioid receptor within in the body to create a certain effect, the effect that we have for pain control, the effect that we can have for euphoria. The medications that work on those sites also can have side effects that we experience, like constipation for example. Really it depends on if they activate or block on a certain receptor. Buprenorphine has a unique property in the fact that it actually can active certain opioid receptors. It’s a blocker on certain opioid receptors. It has a high affinity, meaning that it binds quite well to the mu receptor that other opioids bind to. Depending on the dosage, depending on another’s medications presence on that receptor, and depending on which receptor we’re talking about, it can act like an agonist activator or an antagonist blocker. It’s a lot of pharmaceutical jargon there. But the point is, it’s hoped to help decrease illicit substance use and use it to prevent further harm from that illicit substance use.
Hayley: How does a clinician determine who gets this medication and who gets which one?
Dr. Bhatt: I think historically, it depends what school of thought people come from. Many people who come from an abstinence base model or philosophy or thinking, believe that you’re only in recovery or sobriety if you’re not taking anything. I think the science has shown that that can occur with medicines prescribed that are not used in an addictive manner on board. For example, if somebody’s using heroin and they’re using it and they’re getting high. They’re using it of course in an illicit manner, getting something prescribed to help you not use illicit substances in an addictive manner, but help you live a healthy life and not have further harm, not catch an infectious disease, not have an overdose. Well, that’s really what the intention is of these medications. Now, who’s going to go for this and who’s not really depends on the patient’s background. I think all patients who suffer from an opioid use disorder in this day and age should have a medication considered to have a comprehensive treatment program put into place because addiction is a very broad disease. It’s made up of psychological and social and physical influences. All of those influences need to be considered when thinking about what areas of treatment need to be addressed. We need to address things psychologically. We need to address thinking socially. We need to address things biologically. The short answer is all patients with opioid use disorders should have medications considered to see if they’re eligible or not and if they’re good candidates or not. And the studies show that people who are prescribed medications do have favorable outcomes. They stay in treatment longer. They stay away from illicit substance uses longer. They don’t overdose as often. There’s a lot of benefits that have been shown in multiple studies that when we do have biological medicines used for opioid use disorders there are favorable outcomes.
Hayley: And one of those benefits is that it helps with withdrawal, right?
Dr. Bhatt: Yes, definitely. It helps with cravings. It can help with withdrawal. Obviously, the goal is to not use substances in an illicit manner and to keep the person from suffering from their harm. For all of those reasons, medications for opioid use disorders are there. But I think what we’re looking at is also a big question of, are those individuals being educated adequately on those medications and what these medications can do. I think that’s a big question that sometimes has gone unaddressed. Because in the attempt to correct or address this opioid epidemic, we’re giving medications out. Some that can cause physical dependency. Now, even though these studies that I just mentioned have shown favorable outcomes, we do have an obligation to, as prescribers, to create a comprehensive treatment plan. And that should include ancillary supportive psychosocial modalities that address the psychological and social parts of the addictive process. We can’t have a one stop shop when it comes to treating addiction. I think that’s where a big point of this discussion is today, that medications alone also cannot be the answer. Although we should not stop somebody from taking medications if they’re not doing psychosocial interventions. That’s not the point here. But the point is also that psychosocial medications cannot be excluded. And I think that’s really what we’re trying to emphasize.
Hayley: You’re saying that in your experience, people don’t understand or they’re not completely informed that these drugs can cause a physical dependency?
Dr. Bhatt: A lot of times in clinical practice we have people come in and they’re younger individuals. They’ve often been prescribed, not the antagonist- the antagonist medications like naltrexone, that decrease cravings and that can promote abstinence. These are not things that cause physical dependency. These are not opioid receptor agonists. They do not activate the opioid receptors and they don’t cause physical dependency. I’m talking about when we use other medications like methadone, or buprenorphine, we have to educate these people as part of their comprehensive treatment plan. These medications will cause a physical dependency and that you should use this with a plan. A complete comprehensive addiction recovery program that address the psychological components of their addictions, the social, ecological, the whole person’s addictive issues. My fear is that many practitioners who are practicing and treating those with opioid use disorders are giving these medications out. Many times the patients are getting prescribed these medications and they’re not receiving all these other parts of treatment. Now, could that be due to the person suffering with the addictive disorders? Is it due to them or is it due to the practitioner not factoring in or emphasizing all of these other components? I’m seeing it on both ends. I see a lot of patients, younger people who come to me and say, “Doctor, I did not know that I was not going to feel or get the response that I wanted. I was prescribed this buprenorphine, or I was prescribed this medication and now I’m still using my illicit substances. I’m addicted to both things and physically dependent to both things”. And I think this is really my question here today is how that is being addressed. I’m seeing this as a problem as we go to address the opioid epidemic.
Hayley: Right because that is a problem. If they’re not receiving other forms of treatment or therapy, and they’re just taking another medication, is that really working to help them with their addiction?
Dr. Bhatt: Exactly. There’s an algorithm with substance abuse and mental health services administration. They’ve developed practice guidelines and they’re there for the practitioner to follow to look into who the right candidate is. That includes somebody who has an opioid use disorder. Somebody who’s engaging in risky behavior. Somebody who’s going to potentially die from using this stuff. Again, we want to make sure that all the ammunition that’s available out there is given or offered to these patients. But at the same time, I don’t want to use this overzealous, aggressive stance to address- I don’t want it to be misconstrued. Yes, we want to open the doors for practitioners to prescribe these medications to address the opioid disorders. But in those attempts, we don’t want to miss the point. We don’t want to lose the global comprehensive message that patients cannot just come off these drugs without understanding that addiction is a bigger picture than just taking a pill to get off their opioid use disorders. There are other factors that they need to address. People have psychiatric, psychological conditions that are leading to their depression. People have environmental issues that are contributing to their addiction, and these are things that need to be considered and factored in. These medications are there. They’re scientifically proven to help people, but they need to be part of a package. If somebody’s not engaging in psychological social issues, I’m not saying to remove the biological medications. But we want to ensure that the patient is aware and educated that this is something that they will become physically dependent on, that if they do want to come off it that there would be a titration plan put in place. All of these should be discussed upfront when prescribing somebody these medications. That’s responsible prescribing.
Hayley: How long do you see people on these medications? Is it months or years?
Dr. Bhatt: It really depends on the individual. There are people that might need to be on these medications for the rest of their lives. Because ultimately, if the quality of life has improved, and being on these medications prescribed by a practitioner, they take it as prescribed- they’re not using it in a diverted manner. They’re staying away from using other illicit drugs, able to engage in work, able to be responsible with their families and take good care of their obligations. They might need to be on it for the rest of their lives. If doing so creates a great quality of life otherwise, those people will stay on it. But then there’s other people who will be started on it, who will be able to get a robust understanding of what factors influence their substance use. They might have been doing it under a period of stress or distress. Certain factors change in their lives that they’re able to attempt to come off these things. And with a good recovery plan and with their doctor or prescriber in hand, they can be slowly titrated off those medications. It really depends on the individual, and we’ve seen both. People stay on it and people come off of it, but it’s really based on the individual’s services.
Hayley: Okay, I want to clarify something. If somebody is on methadone or buprenorphine for years and they come off of it, are they going to experience withdrawal symptoms?
Dr. Bhatt: If they come off of it quickly, yes. Because of the physical dependency nature of the medication, it can cause physical withdrawal. That’s really the point of this whole thing. That although yes, we do have to take the lesser of two evils or we have to take these things into consideration, and again, let me correct that phrasing. Methadone or buprenorphine are not evil. It’s a prescribed medication that has shown tremendous effectiveness to help somebody live healthy lives. But, with it comes a physical dependency due to the pharmaceutical nature of that. I just want to be clear that in our attempts to fix something that was a result of prescribing controlled substances- opioids, or people using heroin, illicit substances, we want to ensure that in our attempts to correct the opioid epidemic that we’re doing it in a prudent way. That when we prescribe medications that also have physical dependency as a consequence, or as a replacement, we want to just ensure that everybody’s aware of what they’re getting on. And that they understand that if they want to get off of it, what the steps will be and that they need to come off of it slowly. That there should be a plan of action and it should be done collaboratively with their physician. It takes a lot of supervision, and it takes a gradual approach. And that should all be, again, discussed upfront. A lot of times people are coming in with their addictive behaviors and they get a prescription. They’re not given that comprehensive package. They’re just going to end up using both. Unfortunately, I’ve seen people then say, “Oh, this medication never worked for me. I’ve tried it”. It’s failed, but it’s often because they weren’t set up on a path to be successful. And that’s really starting with having a proper plan in place from the beginning.
Hayley: I want to talk about having that proper plan. What are the regulations currently before somebody gets one of these medications? And what about it do you think needs to change?
Dr. Bhatt: What happens is we have the Controlled Substances Act. And what happened many years ago was that when we had increased controlled regulations on people prescribing medications to help people with opioid use disorders. We wanted to make sure people were educated. We wanted to make sure prescribers knew what they were doing. And we set up these processes where you obtain a waiver that you were able to prescribe buprenorphine. This allowed buprenorphine to be prescribed by outpatient physicians who had this waiver and were able to do so after they received eight hours of education, specifically to do this. As the opioid epidemic has worsened and we’ve seen more and more cases, especially during the pandemic, we’ve seen a sharp increase in overdoses and death. In April of 2021, we saw practitioners have the privilege of being able to prescribe it, as long as they had a DEA license. I’m being a little bit succinct here, but the bottom line is that the need for that waiver was no longer required. With it, there was some informal requests by a regulatory body to ensure that look, if you want to prescribe it, we need help. We need people to have access to more practitioners who have the ability to prescribe these scientifically proven medications. In the end, we have a current situation where more practitioners who have a DEA license have the authority to prescribe buprenorphine, for example. That’s great. But again, going backwards, we know that one factor for this opioid epidemic was the overzealous prescribing of pain medications. Then all of a sudden, these pain medications were regulated significantly. And then we had people going out and using heroin. Now we have a lot of people prescribing buprenorphine. Be it that’s scientifically proven and all of that, we just need to be educated, aware, and thoughtful of the fact that if we’re putting people on medications that do cause them physical dependency. Make sure that we’re educating our individuals. Make sure that we are educated as practitioners. And ensure that we have a proper plan and not to forget that we need to have a comprehensive treatment plan in place. We are addressing all of the other factors that make up somebody’s addiction beyond just the biological and physical dependency withdrawal which the buprenorphine, the methadone, and the naltrexone’s address. And not to forget that in our attempts to address this huge problem.
Hayley: I read that 18% of people with an opioid use disorder have received treatment from one of the medications that you just mentioned. Is that number too big or too small?
Dr. Bhatt: Well definitely, it’s too small. I don’t want this messaging that we’re providing today to get mixed. I’m not saying that we need to not prescribe. I’m actually advocating that every patient with an opioid use disorder needs to have buprenorphine considered because it works. It works for many people. But, I want it to be prescribed responsibly. I want it to be prescribed with careful thought and it needs to be prescribed in the proper context, because risk versus benefits needs to be discussed. Comprehensive treatment programs need to be cultivated. 18% means not enough people are being offered this medication or have it considered. I do believe there’s a lot of historical stigma that a lot of people out there believe that abstinence is the only way. Abstinence even meaning a prescribed medication that has been proven to help should not be considered because then you’re not truly in recovery. Or you don’t have sobriety. But, I don’t think modern physicians and scientists look at it that way. We do look at being prescribed medication to help us live a healthy life and to avoid living an addicted type of life is actually treatment. It’s not replacing one drug with another. Especially if this is done in a proper manner. It’s saved a lot of lives and it’s definitely promoted a harm reduction. That’s really what we want to achieve here. People having a higher quality of life and not use illicit substances and prevent these overdoses that are happening.
Hayley: These are prescription medications, but are these drugs ever abused on the streets?
Dr. Bhatt: I mean unfortunately, people do abuse substances that can potentially in their mind create some sort of euphoria or get them high. People are quite ingenious in ways of doing this. Naltrexone is not something you can get high off of because it’s an opioid blocker. Methadone and buprenorphine do have some sort of ceiling effects to them. But in the attempt to achieve any sort of pleasure, we have seen people inject these medications, use multiple ways to try and get high. This an unfortunate part of the disease of addiction, that they’re going to use even medications that are here to actually prevent them from using them in an illicit manner. They are doing so. It’s out on the street, and it’s being used on the black market so to speak, that people are buying and selling these things. They’re getting prescriptions and they’re selling it to people who are willing to buy. That’s unfortunately the problem with this. But all in all, we have tried and pharmaceutical companies have invented methods to limit the diversion of these medications. For example, buprenorphine alone has been manufactured and then also a different formulation has been created to add an opioid blocker to it. If somebody was not to take it orally but try to inject it, that it would stop the buprenorphine from being active. The potential for getting high is diminished. There are attempts to keep this from being diverted and to help people use this in the way that it’s intended. But, is the potential there? Yes, but if you do it in a proper way. If people who are prescribing early on do not dispense large amounts of these medications, determine that proper urine drug testing is done to see that people are not using other illicit substances. And do it in a gradual way so the patient starts to gain more autonomy and the practitioner who’s prescribing has gained trust and confidence of the patient, then the patient should be given more of a supply. Methadone, it’s being given out many in clinics, so people are only getting a day’s worth of supply at a time. These are all ways that people are regulating and keeping it from getting out on the street. These are important steps that we need to take to ensure that we limit diversion of these medications.
Hayley: In that clinical setting, is there a financial gain for the providers of these opioid treatment medications?
Dr. Bhatt: We have to look at the reality of this. Obviously as practitioners when you prescribe medications to individuals who need it, there are fees associated with it. When you say financial gain, obviously you can develop your practice to focus on this stuff. You are going to get compensated to prescribe these medications, because you’re providing a service. You’re seeing a patient. You’re providing your medical and clinical expertise. You’re evaluating them. You’re doing tests. You’re making assessments and then you’re providing medications. And that type of service needs to be reimbursed. Now, could that mean that people are going to consider volume as a factor in seeing more patients so they can earn more revenue? I think that’s part of, unfortunately, capitalism, and part of business anywhere. I guess people out there, and again, I’m not trying to call out any practitioner whose focus is on seeing as many patients as they can to help address that. Because I think you can spin it both ways. The more patients that are seen, more patients that are prescribed, more patients that can get off of illicit substances and get their help, well that’s just more people that are not using illicit substances or getting treatment for their opioid use disorders. But could there be practitioners out there that do a robust business? And in that robust business maybe see volume over quality. And maybe some of these comprehensive components of what we are advocating here be compromised, I would say that could happen. That’s what we’re hoping does not happen and that’s what we’re trying to emphasize here. At the end of the day, I believe if done correctly and done with the proper checks and balances in place, we can continue to have practitioners out there prescribing these medications, addressing their opioid use disorders, using this as part of a comprehensive treatment plan. But at the same time, it can’t be compromising components of it by just sheerly doing volume, because then we’re not helping anybody. Again, that’s up to that individual practitioner. But that’s where we need to have the government and regulatory bodies watching prescribing limitations. And we have these things in place to ensure that people are not just overzealously prescribing medications for the sheer purpose of gaining revenue. That’s where we do have caps on these things and how many patients, we can prescribe these things for and it needs to stay in place. We can’t just have people running amuck and prescribing hundreds and thousands of people prescriptions, because I think we’re going to fall into the same problem that got us into this situation. It’s a double-edged sword if not done correctly.
Hayley: That’s true. As we close out this topic, I want to add that if you have an opioid use disorder, don’t wait to look for help just because you’re not sure what to do. There are so many accidental overdoses that could have been prevented by someone seeking treatment. Because like you said, Dr. Bhatt, there are a lot of options and someone should take the time to explore all of the choices that they have. You can learn more at addictioncenter.com, and we hope to have you again for another episode of Straight Talk With The Doc.