Breaking News
September 26, 2018 - Blood-brain barrier can be important biomarker for early diagnosis of Alzheimer’s disease
September 26, 2018 - Scientists discover and characterize human skeletal stem cells
September 26, 2018 - Repeat CT Common in Peds Traumatic Epidural Hematoma
September 26, 2018 - Genetics Home Reference: bunion
September 26, 2018 - Increase observed in hearts from drug-intoxicated donors
September 26, 2018 - For Heart Failure Patients, Mitral Valve Procedure Improved Outcomes
September 26, 2018 - TINY cancer detection device shows promise as point-of-care detector of KSHV
September 26, 2018 - Women with non-small cell lung cancers live longer than their male counterparts
September 26, 2018 - KTU researchers engineer experimental bone to help treat osteoarthritis patients
September 26, 2018 - Foundation for a Smoke-Free World calls for proposals to implement Smoke-Free Index
September 26, 2018 - Functional Imagery Training helps lose five times more weight than talking therapy
September 26, 2018 - Fewer American Teens Having Sex, Most Using Birth Control
September 26, 2018 - We are predisposed to forgive, new research suggests
September 26, 2018 - Insomnia Exacts Heavy Toll on Quality of Life
September 26, 2018 - Clinical study shows efficacy, safety of novel drug-eluting stent with improved radiographic visibility
September 26, 2018 - Cytox, AIBL announce expanded agreement to assess genetic risk for Alzheimer’s
September 26, 2018 - Study finds persistent rate of lawnmower injury-related emergency department visits
September 26, 2018 - Researchers find molecule that halts, reverts neurodegeneration caused by Parkinson’s disease
September 26, 2018 - Novartis announces winners of 2018 eXcellence in Ophthalmology Vision Award
September 26, 2018 - New spinout company to tackle drug-resistant infections with novel antibiotics
September 26, 2018 - In depression the brain region for stress control is larger
September 26, 2018 - Smuggling RNA into cells can activate the immune system to fight cancer
September 26, 2018 - Special Focus Issue takes wide view of complementary and integrative medicine in cancer
September 26, 2018 - Researchers now confirm that genome duplication drives evolution of species
September 25, 2018 - Study provides evidence of beta lactamase producing, antimicrobial resistant E. coli in U.S. retail meat
September 25, 2018 - UCI study finds new cause of cerebral microbleeds
September 25, 2018 - Researchers propose mechanism by which ASTN2 protein defects lead to brain disorders
September 25, 2018 - Chinese and German researchers to cooperate more closely in future for better food
September 25, 2018 - Recent study helps predict probability of pregnant mothers to have child with autism
September 25, 2018 - New online, sound matching tool offers tinnitus sufferers potential treatment options
September 25, 2018 - UC Davis researchers take critical step in developing more effective Salmonella vaccine
September 25, 2018 - Antibiotics best paediatric treatment for children’s chronic wet cough
September 25, 2018 - Looking beyond opioids: Stanford pain psychologist briefs Congress
September 25, 2018 - Organs actively fighting back against autoimmune diseases, finds study
September 25, 2018 - Lancaster professor aims to understand how genes affect smoking cessation
September 25, 2018 - Human-oriented perspective needed to better understand Parkinson’s disease
September 25, 2018 - Physical activity may have beneficial effects for people with rare Alzheimer’s disease
September 25, 2018 - FDA Updates on Valsartan Recalls
September 25, 2018 - 3-D-printed tracheal splints used in groundbreaking pediatric surgery
September 25, 2018 - Who is the designated driver, or proxy, for your health decisions?
September 25, 2018 - New chemo-optogenetic method enables multi-directional activity control of cellular processes
September 25, 2018 - Study explores link between genetic predisposition to Alzheimer’s and cardiometabolic risk factors
September 25, 2018 - NeoTract presents new clinical data from studies of UroLift System for patients with BPH
September 25, 2018 - Patients with paralysis manage to walk thanks to new technology
September 25, 2018 - Statins Improve Long-Term Survival After AAA Repair
September 25, 2018 - Novel brain network linked to chronic pain in Parkinson’s disease
September 25, 2018 - Researchers reassess negative pressure wound therapy as its benefit and harm remain unclear
September 25, 2018 - Older adults with ‘fall plan of care’ less likely to suffer fall-related hospitalizations
September 25, 2018 - FDA lifts partial clinical hold that paused enrollment of new patients in tazemetosta clinical trials
September 25, 2018 - IME Medical Electrospinning establishes state-of-the-art manufacturing lab facilities
September 25, 2018 - Phase 1 and 2 clinical trials of entrectinib drug in ROS1-positive NSCLC show promising results
September 25, 2018 - How to Protect Your Eyesight
September 25, 2018 - Novel approach allows researchers to define how cells in the retina respond to diabetes
September 25, 2018 - Columbia University announces winners of 2018 Louisa Gross Horwitz Prize
September 25, 2018 - New model enables anyone to run powerful simulations, complex calculations easily
September 25, 2018 - Clinical trial investigators found non-compliant with requirement to report results on EU register
September 25, 2018 - Study analyzes quality of protein supplements in function of source, treatment and storage
September 25, 2018 - FDA grants Orphan Drug Designation to Myelo001 for treatment of Acute Radiation Syndrome
September 25, 2018 - U.S. Alzheimer’s Cases to Nearly Triple by 2060
September 25, 2018 - Improving cell replacement therapy for Parkinson’s disease
September 25, 2018 - Genervon reports new findings that drug candidate GM6 attenuates Alzheimer’s disease in mice model
September 25, 2018 - FDA approves new 5 mm diameter drug-eluting stent from Cook Medical
September 25, 2018 - New $17.8 million grant ensures USC at forefront of research on tobacco-related health risks
September 25, 2018 - Researchers analyze response to combination immunotherapy for patients with rare skin cancer
September 25, 2018 - Study sheds light on how brain protein may be involved neurodevelopmental disorders
September 25, 2018 - Where to draw the line on incentives
September 25, 2018 - Solid fuel use linked with increased risk of hospitalization or death from respiratory diseases
September 25, 2018 - ‘Trouble Brewing’ report highlights steps that governments can take to reduce alcohol-related harms
September 25, 2018 - Recurrence risk of VTE appears similar for patients with cancer and those with unprovoked VTE
September 25, 2018 - Global leaders must make bold commitments at first-ever UN tuberculosis summit
September 25, 2018 - Brief sleep intervention works long-term to prevent child obesity
September 25, 2018 - Vaping among kids and teens a growing concern
September 25, 2018 - Public launch of products and application solutions from Porvair Laboratory Division
September 25, 2018 - Harmful H. pylori may play a role in Parkinson’s disease
September 25, 2018 - Researchers develop way to measure different types of fear of falling in patients with Parkinson’s
September 25, 2018 - Fracture causes bone density losses throughout the body
September 25, 2018 - Researchers highlight potential therapy for treating rare, deadly blood-clotting disorder
September 25, 2018 - Hybrid theranostic complex shows high therapeutic efficacy against tumor cells
September 25, 2018 - FDA Issues Statement Reaffirming the Positive Benefit-Risk Profile of Nuplazid (pimavanserin) for Patients with Hallucinations and Delusions Associated with Parkinson’s Disease Psychosis
September 25, 2018 - Toxicological evaluation and dosimetry estimation of potential PET radiotracer
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