HJLR May/Jun 2019

50 MAY / JUN 2019 I  Healthcare Journal of LITTLE ROCK dialogue column medicaid An estimated two million people in the United States suffer from opioid use disorder (OUD), due to the routine use of prescription and illegally-obtained opioids. America’s opioid crisis has resulted in a large number of people who have become dependent on narcotics. Effective long-term solutions to the medi- cal management of these patients remains a challenge to both office-based clinicians and program administrators. People who have OUD often surface in the emergency room or the justice system. Many then get pulled into ongoing health care, frequently with considerable delay in the start of treatment. While dose reduction is often possible, abstinence remains a chal- lenge. The practice of prescribing less opioids has driven patients to use dangerous street drugs. Subsequent black-market purchases create economic burdens that often result in criminal activity or exploitation of family to maintain a constant supply of narcotics. Medication assisted treatment (MAT) has evolved into a core strategy to sustain these patients initially. Use of substitutes such as buprenorphine/naloxone, methadone, or ex- tended release naloxone were thought to be a transitional bridge to wean patients from narcotic dependency. Unfortunately, many OUD patients relapse shortly after the cessa- tion of MAT. Many addiction specialists now view buprenorphine/naloxone as a lifelong therapy, much like metformin is a core “for- ever drug” in type II diabetes. MAT drugs have problematic aspects that raise many questions. What is the appropri- ate dose for this medication? How high a dose should be sustained over time? What are the risks of buprenorphine/naloxone if mixed with other psychotropic agents? Is buprenorphine/naloxone, if not properly monitored, a drug of abuse itself? Should medication assisted treatment be adminis- tered without counseling or other addiction supportive services? Should these agents be used to treat pain in addition to patients with OUD? How does one safeguard against abuse of methadone, a potent opioid with its own track record of overdoses in opioid naïve pa- tients? There is considerable need for new research to clarify strategies and discover new, effective treatments of OUD. In March 2019, the National Academies of Sciences released a major white paper on Dilemmas of M edication A ssisted T reatment