New protocol says meds can help treat addiction

Saying it's an exciting time for the use of medications to treat opioid addiction, the federal Substance Abuse & Mental Health Services Administration (SAMHSA) has released a protocol giving details of the clinical pharmacology, screening, treatment matching, and other aspects of recommended use.

Written by a panel of five substance abuse experts, the treatment improvement protocol (TIP) gathers what experts say is the best treatment advice for using methadone, naltrexone, and buprenorphine, largely for addiction to prescription narcotics or heroin. It will be distributed free in hard copy and on-line.

The protocol is the first overview of the practice area by the agency since buprenorphine became the first drug approved for treatment of opioid addiction in physicians' offices. That came about due to the Drug Addiction Treatment Act of 2000 and Food & Drug Administration action in 2002. Since that time, about 6,000 physicians have obtained the special accreditation required to do the prescribing.

At the press conference introducing the publication, Westley Clark, M.D., J.D., director of SAMHSA's Center for Substance Abuse Treatment, said the TIP "provides the basic template for opioid treatment programs and for clinicians ... so that they know what best practices are and can judge for themselves in their local communities. We are very aware that we have more than 1,100 treatment programs in existence and that they are not all uniform in quality."

Clark also said, "Studies have shown that detoxification alone may provide only short-term benefits when patients are addicted to prescription narcotics or heroin. We may need to retain patients in treatment over an extended period of time to obtain successful outcomes, just as we do for other chronic diseases such as diabetes and asthma."

One of the panel members, Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence, noted that in 1993 there were about 115,000 patients in 750 approved methadone treatment programs. Now there are 241,000 patients in 1,150 programs in 45 states. And, he said, the field is still changing dynamically. For example, he noted, more young people are becoming addicted to opiates, including prescription opiates, and are seeking methadone treatment.

Janice Kauffman, R.N., MPH, director of the addiction psychiatry service at Brigham and Women's Hospital, another panel member, said she feels the advent of buprenorphine is an opportunity for adolescents who have the support of their families to be treated-something she thinks will increase as providers become better at using the medications.

The protocol says that although the number of people in treatment has expanded, only about 20% of the estimated 898,000 heroin users in the United States are being treated. And the proportion is even lower for people who abuse prescription opioids.

Clark also noted the publication addresses the conundrum physicians face in treating an aging population with more people in need of pain medication. Ambulatory physicians need to include in their skills, he said, "the ability to treat those people-who are a minority of individuals who receive opioid therapeutics-who develop abuse and addiction problems as a result of iatrogenic medication."

Kauffman pointed to the protocol's specific outlines of treatment skills, saying, for example, its recommendations supersede the arbitrary ceilings assigned for methadone "that really weren't based on science, were based in fear, were based in myth, were based in stigma and lack of knowledge." The protocol, she noted, documents the science behind adequate dosing, individualized for the patients. For instance, she said, "Some patients require some higher doses because they are taking medications for other concurrent illness that interfere with the metabolism of methadone. So you might have to adjust the dose."

Along those lines, the document also offers advice for helping the addicted patient who has pain from surgical procedures or other factors.

"Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs, A Treatment Improvement Protocol, TIP 43" is available at http://ncadi.samhsa.gov/.