Breaking News
March 22, 2019 - Servier collaborates with Harvard researchers to fight metabolic diseases
March 22, 2019 - National Eating Disorders Association
March 22, 2019 - Pumping up red blood cell production
March 22, 2019 - Excessive phosphate fertilizer may hurt plants by altering microbial composition in soil
March 22, 2019 - Medical marijuana laws could be improving older Americans’ health, study suggests
March 22, 2019 - Study indicates the benefits of stopping aspirin in heart attack patients
March 22, 2019 - Deep brain stimulation offers significant relief for patients with treatment-resistant depression
March 22, 2019 - Mental health problems in young adults on the rise
March 22, 2019 - Innovative membrane offers a viable solution for periodontitis
March 22, 2019 - The FDA Grants Rare Pediatric Disease Designation to Odiparcil for the Treatment of MPS VI
March 22, 2019 - insulin therapy: MedlinePlus Medical Encyclopedia
March 22, 2019 - Guidelines on the use of genetic testing in psychiatry
March 22, 2019 - Aspiring Doctors Seek Advanced Training In Addiction Medicine
March 22, 2019 - A change in focus could enable the development of new treatments for Alzheimer’s disease
March 22, 2019 - A new way to visualize the immune cell “landscape” of bowel cancer tumors
March 22, 2019 - Understanding maintenance of quiescent stem cells in chronic myelogenous leukemia
March 22, 2019 - Ludwig scientists to share advances in cancer research at AACR Annual Meeting 2019
March 22, 2019 - Less invasive valve replacement can be safe and effective alternative for healthier patients
March 22, 2019 - Aphasia research reveals new, complex interactions between thought and language
March 22, 2019 - Artificial neural networks can predict how different areas in the brain respond to words
March 22, 2019 - Age-related changes to gut microbiome have adverse impact on vascular health, study shows
March 22, 2019 - Isolated seniors chat online to prevent cognitive decline
March 22, 2019 - Naltrexone implant more effective in reducing relapses in HIV patients with opioid addiction
March 22, 2019 - The Brain Institute wins $7.04 million grant to investigate ‘neurophilosphy of free will’
March 22, 2019 - Karyopharm Announces FDA Extension of Review Period for Selinexor New Drug Application
March 22, 2019 - Eruptive xanthomatosis
March 22, 2019 - Cause of vascular disease in kidney failure reversed in animal model
March 22, 2019 - Researchers discover possible new therapeutic strategy for pancreatic cancer
March 22, 2019 - Ebola spreads to second largest city in DRC
March 22, 2019 - Perivascular spaces contribute to worse cognitive health in older adults
March 22, 2019 - Adolescent daily users more likely to obtain electronic cigarettes from commercial sources
March 22, 2019 - FDA Approves Genentech’s Tecentriq in Combination With Chemotherapy for the Initial Treatment of Adults With Extensive-Stage Small Cell Lung Cancer
March 22, 2019 - Diabetes myths and facts: MedlinePlus Medical Encyclopedia
March 22, 2019 - TGen and ABL pursue global rollout of advanced TB test
March 22, 2019 - Traffic light labels influence people to choose healthier and more sustainable meals
March 22, 2019 - Alzheimer’s patients using antiepileptic drugs have twice the risk of pneumonia, study shows
March 22, 2019 - Skin diseases may be more prevalent than previously thought
March 22, 2019 - Overall rates of death from breast cancer are falling across the EU
March 22, 2019 - Novel plasmid could hold key to control of mosquito-borne illness
March 22, 2019 - Female Emergency Physicians Paid Less Than Males
March 22, 2019 - Estimated average glucose (eAG): MedlinePlus Medical Encyclopedia
March 22, 2019 - Experimental drug could be new option for type 2 diabetes
March 22, 2019 - Five Things To Know About The Electronic Health Records Mess
March 22, 2019 - TMJ disorders could be treated with tissue-engineered implants after successful animal study
March 22, 2019 - Team-based approach is key to successful care of pregnant women with heart failure
March 22, 2019 - Study identifies gene variant associated with accelerated cellular aging
March 21, 2019 - Salk scientists show how background noise from neurons can interrupt focused attention
March 21, 2019 - New class of drugs could help treat patients diagnosed with ovarian cancer
March 21, 2019 - Tecentriq Approved for Small Cell Lung Cancer
March 21, 2019 - Adipocyte glucocorticoid receptors play a role in developing steroid diabetes
March 21, 2019 - Climate change can affect nutrient content of crops, harming human health
March 21, 2019 - Podcast: KHN’s ‘What The Health’ Surprise! Fixing Surprise Medical Bills Is Harder Than it Looks
March 21, 2019 - Chemistry researchers patent new method for making anti-leukemia compounds
March 21, 2019 - UIC scientists identify hidden proteins in bacteria
March 21, 2019 - New Australian drug trial achieves remarkable results in patients with acute myeloid leukemia
March 21, 2019 - Females live longer when they have help raising offspring
March 21, 2019 - How did orthodontists sell orthodontics?
March 21, 2019 - In the Spotlight: From dietitian to physician assistant student
March 21, 2019 - The CRISPR Revolution: What You Need to Know
March 21, 2019 - FDA Chief Calls For Stricter Scrutiny Of Electronic Health Records
March 21, 2019 - Combined glucocorticoid and antioxidant therapy could benefit premature babies
March 21, 2019 - Low levels of certain eye proteins could serve as predictor for Alzheimer’s
March 21, 2019 - Post-traumatic holocaust survivors transmit negative views on aging to offspring
March 21, 2019 - City of Hope receives $7.5 million in grant awards to study cutaneous T cell lymphoma
March 21, 2019 - New video game-led training device helps stroke survivors regain arm mobility
March 21, 2019 - Compounds in coffee could slow prostate cancer growth
March 21, 2019 - New mobile DNA element in Wolbachia may contribute to improved disease control strategies
March 21, 2019 - Phase 2 Clinical Trial of Bermekimab Shows Potential New Standard of Care for Treatment of Hidradenitis Suppurativa, Including Significant Pain Reduction without Antibiotics
March 21, 2019 - More than one-third of patients risk major bleeding by doubling up on blood thinners
March 21, 2019 - A skeptical look at popular diets: Thumbs up for Mediterranean
March 21, 2019 - PTSD After Cardiac Arrest Predicts More Heart Trouble
March 21, 2019 - Role of immunological imprinting in elicitation of new antibodies
March 21, 2019 - Breast cancer relapse predictor tool may soon be a reality
March 21, 2019 - New computer program developed by TGen lights up cancer-causing genetic mutations
March 21, 2019 - FDA warns two breast implant makers for failure to comply with post-approval study requirements
March 21, 2019 - Butler Hospital receives COBRE grant to enhance research on neuropsychiatric illnesses
March 21, 2019 - Majority of osteoporosis clinical practice guidelines ignore patients’ voices
March 21, 2019 - Generic messages don’t help patients to lose weight
March 21, 2019 - Eisai and Imbrium Therapeutics Announce U.S. FDA Filing Acceptance of New Drug Application for Lemborexant for the Treatment of Insomnia
March 21, 2019 - Two-drug combos using popular calcium channel blocker show superiority in lowering BP
Non-addictive pain medication changing therapy for substance use disorders

Non-addictive pain medication changing therapy for substance use disorders

image_pdfDownload PDFimage_print
How treatment for addiction came out of the Dark Ages
Credit: Yale University

“It’s not often that a psychiatrist gets to hear ‘Doctor, you saved my life,’ ” said Ellen Edens, M.D., FW ’09, assistant professor of psychiatry and associate fellowship director in addiction psychiatry. But she gets that a lot from patients receiving outpatient treatment for opioid use disorder. “They tell me, ‘I have my children back, I’m working, I feel good.’ ”

Treatment for opioid use disorder hasn’t always brought such clear rewards. Throughout the 1960s, abstinence-based detox was the only widely available treatment despite high relapse rates. Then, in 1965, methadone clinics emerged as a game-changer.

Rockefeller University clinicians Vincent Dole, M.D., and Marie Nyswander, M.D., reported in JAMA: Journal of the American Medical Association that year that they had used once-daily oral methadone—an opioid painkiller—to stabilize 22 young men who were addicted to heroin. Methadone relieved both withdrawal and cravings, and allowed patients to resume their lives. On September 15, 1969, Robert DuPont, M.D., who would become the first director of the National Institute on Drug Abuse, started the first methadone maintenance treatment program, which served 25 parolees in Washington, D.C.

“That is when treatment for opioid use disorder emerged from the Dark Ages,” said Patrick G. O’Connor, M.D., M.P.H. ’88, FW ’88, the Dan Adams and Amanda Adams Professor of General Medicine, and chief of general internal medicine.

As methadone clinics opened in cities around the country, studies showed that the treatment decreased drug use and opioid overdoses, lowered hepatitis B and C rates, improved pregnancy and birth outcomes, increased overall survival, and—crucially—lowered risk for HIV infection.

But the groundbreaking treatment wasn’t perfect. Patients who landed a coveted spot in one of a handful of licensed clinics had to show up every day for their dose until they were deemed trustworthy enough to take a supply home. That process could take months. As heroin users tried to escape the soaring risk of HIV infection in the late 1980s, the model could barely support the demand.

“Here in New Haven, we had waiting lists of six to 12 months for a slot in a methadone clinic,” said O’Connor. “People were literally dying while they were waiting for this highly effective treatment.”

O’Connor and colleagues at Yale knew there had to be a better way. “What if we developed an approach to treating opioid dependence that didn’t rely on one or two methadone programs in New Haven, but rather was available in primary care clinics and physicians’ offices all over the city?” O’Connor asked.

Chronic care for addiction

In a 1992 article in the Journal of General Internal Medicine, O’Connor and colleagues showed that they could manage withdrawal from heroin with clonidine, a drug introduced in 1966 to treat high blood pressure and that was found to manage opioid withdrawal. Once opioid-free, patients received naltrexone, an opioid blocker which renders them less able to feel “high” or to overdose when they use heroin. Theoretically, the medication would eliminate the stimulus to use opioids. But cravings persisted and patients often gave up naltrexone and returned to using opioids.

Still, says O’Connor, “We showed that patients would come to primary care for treatment and that we had an effective protocol that could get them to a drug-free state in an outpatient setting.” Integrating addiction treatment into primary care has additional benefits. This model would allow patients to receive both addiction treatment and general medical care “under one roof,” without the stigma of an addiction treatment program.

Because patients often abandoned naltrexone, O’Connor explored a new approach—using opioid maintenance therapy in primary care. Since methadone could be used only in specialized programs, he performed the first randomized trial of primary care-based buprenorphine—an experimental medication that had been found as effective as methadone in specialized treatment programs.

“Our study found that patients who received buprenorphine in primary care did just as well as those who received it in specialized addiction treatment settings,” said O’Connor.

Soon, the Drug Addiction Treatment Act of 2000 permitted physicians who met certain criteria to treat opioid addiction in outpatient offices using FDA-approved Schedule III, IV, and V narcotics, although none were available at that time. Two years later, the FDA approved two drugs that fit the bill.

Subutex (buprenorphine hydrochloride), the partial opioid agonist that O’Connor studied, could alleviate withdrawal and cravings with less risk of overdose or abuse than methadone. Suboxone (buprenorphine hydrochloride and naloxone hydrochloride) added naloxone to decrease the risk of misuse. Both formulations could be administered in a doctor’s office.

Medication-assisted therapy—Subutex or Suboxone in addition to such psychosocial treatment as counseling—became the standard of care. “It was revolutionary,” said Edens. “One patient could be waiting to get their blood pressure checked next to another who is waiting to get Suboxone for opioid use disorder, and nobody knows the difference.”

Researchers, including David A. Fiellin, M.D., HS ’94, FW ’96, professor of medicine, challenged a long-standing belief when they began to show that treatment with buprenorphine combined with primary care physician management was as effective as buprenorphine combined with cognitive behavioral therapy.

Aligning evidence with policy

While treatment has advanced over the last 50 years, policy and medical education lag. Medical school curricula spend little time on addiction. In part because of this neglect, physicians who want to treat patients with buprenorphine must first attend an all-day course. Federal law limits them to treating up to 275 patients at a time in a “qualified setting” that complies with information technology requirements and makes counseling services available. For practical reasons clinicians rarely if ever treat the full 275 patients allotted to them.

“It sends a message to physicians,” said Edens, “that this is a dangerous or abusable system, but buprenorphine is so easy to use, and when it’s misused, it’s usually for the exact reason we would use it: to treat withdrawal.”

But treatment for opioid use disorder won’t stop, now that it’s treated as a chronic condition in an outpatient setting in a manner similar to such other chronic diseases as diabetes. “As with any other chronic disease,” said O’Connor, “we’ll continue to search for new and more effective medication and psychosocial treatment approaches to improve health and save lives.”


Explore further:
Clinical trial looks at tramadol for opioid withdrawal

Tagged with:

About author

Related Articles