How Should Opioid Addiction Be Treated?

The kind of treatment you receive if you are addicted to opioids depends on where you live, a new study found. But all treatment options are not created equal.

Fair Health, an organization that tracks health information, analyzed health insurance claims relating to opioid addiction from five states between 2007 and 2016, and found that each state tends to treat opioid addiction differently. In California, for example, the most commonly used procedure codes attached to claims were related to drug tests and outpatient services. New York listed methadone administration as its most common code, while Texas’ top five codes all involved lab tests.

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The analysis also found where opioid addiction happens. In rural areas, more claims were filed by middle-aged people than by other age groups, while rates were more spread out among the population in urban areas. But making generalizations about urban or rural areas is difficult. The San Antonio area makes up 5% of Texas’ population, but 66% of the state’s opioid-related claims. New York City on the other hand, which makes up 43% of New York’s population, only made up 13% of the state’s opioid claims.

The state-by-state city-by-city discrepancies show that the debate of how to best combat the opioid crisis still rages. In particular, there is still much debate on the value of medication-assisted therapy, and if treatment should aim toward complete opioid abstinence or to a slower treatment assisted with milder opioids like methadone or buprenorphine. While New York seems to prefer methadone treatment, Illinois favors naltrexone treatments that are designed to promote complete opioid abstinence.

Last month, Secretary of Health and Human Services Tom Price made remarks in West Virginia that praised naltrexone after he visited an Alkermes factory, makers of Vivitrol, a brand-name extended release naltrexone. In that same talk, Price expressed doubt about methadone and other opioids used to treat addiction. “If we’re just substituting one opioid for another, we’re not moving the dial much,” Price said. “Folks need to be cured so they can be productive members of society and realize their dreams.” In response, 700 health professionals signed a letter expressing concerns about Price’s views on medication-assisted treatment and affirming their view that medication-assisted treatment is the most effective. HHS stressed that Price was committed to a variety of treatment options and did not want to close off any possible solutions.

Joanna Katzman, MD, Executive Medical Director of the University of New Mexico Health Pain Management Service, told Drug Topics that medication assisted treatment is "considered the most effective modality for the majority of patients with Opioid Use Disorder (OUD). Of course, MAT includes methadone, or buprenorphrine or naltrexone and is always combined with behavioral therapy."

Alkermes recently made headlines for its aggressive lobbying designed to increase sales of Vivitrol. According to an NPR investigation, Alkermes has heavily advertised its drug to lawmakers and law enforcement officials as an alternative to therapies using methadone or buprenorphine. Despite a lack of evidence about the efficacy of using Vivitrol in the treatment of opioid addiction, many are turning to it. NPR found that many states are drafting laws that encourage use of Vivitrol at the expense of other treatment options. According to the New York Times, Alkermes has been lobbying lawmakers and law enforcement agencies, and has made contributions to political campaigns.

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Naltrexone is not the best treatment for everyone, especially pregnant women or those suffering from chronic pain. It requires the user to be completely clear of opioids at the start of treatment, or it can cause a painful detox process. Additionally, Vivitrol is more expensive than methadone or buprenorphine, at nearly $1,000 per shot.

The Vivitrol lobbying, according to NPR, has influenced the debate by changing how lawmakers think about addiction and dependence. Where lawmakers are now more often considering them to be the same thing, health-care workers are quick to point out the difference. According to NPR, “Some doctors compare being dependent on buprenorphine to the dependency someone with diabetes has on insulin: It's simply a medication needed to help manage a chronic condition.”