In a lengthy front page story called: "Addiction Treatment with a Dark Side," The New York Times recently drew attention to buprenorphine, a medication used to treat addiction to heroin and prescription opioids. As physicians and researchers studying addiction and its treatment, we were glad to see attention brought to the issue, but disheartened that the piece focused on patients and doctors involved in the misuse and diversion of buprenorphine, rather than on the lives saved and the harms averted by the appropriate use of this medication. The problem is not with buprenorphine, but with our failure to provide people struggling with opioid addiction appropriate support and access to treatment.
The use of all opioids -- including buprenorphine -- has been dramatically increasing over the past decade. Misuse and overdose are far greater with full opioid agonists (hydrocodone, oxycodone, methadone, heroin etc.) than with buprenorphine. The New York Times article focused on the 420 unfortunate deaths from buprenorphine since 2003, but overall, there are more than 15,500 deaths from opioid overdose annually. In fact, opioid overdose deaths now surpass deaths from motor vehicle accidents. Buprenorphine, along with methadone, remain the most effective treatments for those struggling with addiction to opioids.
Diversion and street use of buprenorphine occur, but much of this illicit use is likely related to lack of access to treatment. Studies report that people are self-treating their withdrawal symptoms or opioid addiction, rather than seeking to get high. Less than 20 percent of those in need of opioid addiction treatment in the U.S. actually receive it, and we know that illicit buprenorphine use is associated with poor treatment access. Additionally, the uninsured, heroin-users, and predominantly people of color, are less likely to receive buprenorphine treatment than those with insurance for opioid painkiller addiction, whom are predominantly white. So poor treatment access affects some groups more than others. With our research, we are studying ways to facilitate entrance into opioid addiction treatment, so we worry that the fear and stigma that is stoked by articles like the one in the Times will only make entering treatment more difficult.
The science is clear -- medication-assisted treatment with an opioid agonist -- like buprenorphine -- is the most effective treatment available for opioid addiction. The benefits for both individuals and communities are well-established and wide-ranging (reduced opioid abuse, reduced behaviors that put people at risk for HIV or Hepatitis C, and even reduced incarceration). Unfortunately, we cannot seem to free ourselves from our beliefs that addiction is rooted in moral failing or lack of willpower, and that those who use medications, like methadone or buprenorphine, are not truly "clean." The stigma surrounding addiction prevents many from seeking treatment and may drive many more to seek abstinence-based treatments instead of more efficacious medication-assisted treatments, because of societal pressure to be "drug free." To treat opioid addiction, we need options that include both behavioral psychosocial counseling and medications. Buprenorphine is not a miracle drug, but it does allow many people to gain control over their addiction.
So what can we do to address the opioid addiction problem? We can increase access to treatment and reduce stigma by ensuring that primary care physicians receive the training and support they need to identify and treat addiction. Primary care physicians are ideally suited to intervene on the opioid epidemic through safer prescribing practices in regards to opioid painkillers, better screening for addiction, and by treating opioid addiction with medications like buprenorphine. Many successful buprenorphine treatment programs have been implemented in primary care settings, and this approach may reduce the stigma of seeking addiction treatment; however, currently, most primary care physicians lack knowledge and confidence about addiction treatment and are often under time pressures. Therefore, addiction is often unidentified and untreated. With improved training during medical school, and continuing medical education and support for primary care practices to integrate addiction treatment, providers could play a meaningful role in addressing the problem.
We may call addiction a disease, but we are a long way from treating it like one. Rather than disparaging buprenorphine and those who prescribe and use it, we should be embracing this medication and ensuring access to and appropriate use of it.
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