More than 115 Americans die every day of opioid overdose. Many more who overdose survive due to the antidote medication naloxone. But a study out Monday finds that just 3 in 10 patients revived by an EMT or in an emergency room received the follow-up medication known to avoid another life-threatening event.
The study, published in the Annals of Internal Medicine, followed 17,568 patients who overdosed on opioids from 2012 to 2014 in Massachusetts. It looked at survival rates over time and whether patients received medicines that treat addiction.
Of the patients who did receive medication, 3,022 adults were on buprenorphine, known by the brand name Suboxone, and 2,040 patients were on methadone. The Suboxone group had a 40 percent lower death rate after one year, compared with those who did not receive any medication. The results for methadone were even stronger: a 60 percent lower death rate.
About 6 percent of patients were on the opioid blocker naltrexone (brand name Vivitrol), but often for just one month. They were no more likely to be alive after a year than those who were not offered or did not take a medication.
“The stunning finding here is that we have effective treatments for people who survive an overdose but only 3 in 10 are getting those medications,” said Dr. Marc LaRochelle, lead author on the study.
For some perspective, LaRochelle mentions the routine recommendation that patients who’ve had another life-threatening event, a heart attack, take aspirin.
“The mortality reduction we see with these drugs is similar to giving someone who suffers a heart attack aspirin. It’s one of the most effective treatments we have in medicine,” said LaRochelle, a primary care physician and researcher at the Grayken Center for Addiction at Boston Medical Center.
But he points to a big difference — 98 percent of people in this country get aspirin for a heart attack.
The gap in care is similar to findings from a U.K. study, but this Boston-based research is the first to follow U.S. patients seen in a hospital or by EMTs, said Dr. Nora Volkow, who directs the National Institute on Drug Abuse.
“A great part of the tragedy of this opioid crisis is that, unlike in previous such crises America has seen, we now possess effective treatment strategies that could address it and save lives,” Volkow wrote in an accompanying editorial. “Yet tens of thousands of people die each year because they have not received these treatments.”
To understand why so few patients get methadone or buprenorphine, one need only cross the street from Boston Medical Center, where LaRochelle works. There are clinics that offer both drugs, and there’s a needle exchange, focused on harm reduction for drug users who are still in active addiction. In the early morning hours, some men and women were lining up for their daily dose of methadone, others were starting their day with a shot of heroin or fentanyl, and two men were trading crumpled bills for two blue tablets.
Scott, a 38-year-old from Lowell, Mass., leaned against a building. He said he has overdosed three or four times, but wasn’t offered Suboxone until after his third overdose.
“The problem is, a lot of these doctors don’t want to prescribe anything like that after the person has an overdose because they feel like they’ll abuse the medicine,” Scott said. We’re using only first names for people who may still be buying illegal drugs.
Scott admitted he has abused Suboxone. It and methadone are both opioid-based medications. Taken as directed, they block cravings for something stronger without making the patient high.
But with Suboxone, “a lot of people that get prescribed it, take a lot more than they’re supposed to and that gives you a high or they sell them to get money,” Scott said.
Others layer alcohol or other medications for a different kind of high. Few doctors are trained to or have experience managing such complex addictions. Scott said he “understands why they’re reluctant to prescribe stuff” like Suboxone.
Sometimes it’s the patient who is reluctant to start medication-assisted treatment.
“There’s a perception that people aren’t quote-unquote ‘clean’ unless they’re abstinent from all substances and that plays into keeping people away from medication treatment, which is the most effective treatment,” said Aubri, who is on methadone and says it works.
But Aubri said the way methadone is delivered is demeaning. Unlike Suboxone, which patients can get from a primary care doctor, during routine medical care, methadone is tightly controlled, typically only available at designated clinics.
“It feels like a jail,” Aubri said. “There’s literal bars across the gates that don’t open til a certain time. There’s security guards. No one wants to be there. The only reason people go is because they need it.”
Many communities continue to reject applications to open methadone clinics. Patients in rural areas often drive more than an hour each way to get their daily dose. The obstacles to care contribute to a feeling among many opioid addiction patients that doctors and hospitals just don’t want to help.
“They treat us like crap,” said Deana, as she hugs her husband Phill. “We’re not like this because we’re bad people, you know.”
Deana and Phill have an endless stream of stories about feeling mistreated in hospitals. But Phill is having the opposite experience now, taking Suboxone, through a clinic at the Boston Health Care for the Homeless Program.
“They give you the counseling, the therapy. It’s like a family,” said Phill, pausing as a ambulance wails by. “They make you feel welcomed and loved and give you that sense of hope that I can have a drug-free life. I don’t have to use.”
Many things have changed since the 2012-2014 period of this study. A growing number of physicians are allowed to prescribe buprenorphine and the number of patients they can manage has increased from 100 to 275. Hospitals are starting to prescribe buprenorphine within the emergency room and opening walk-in clinics for follow-up care. In Boston, there’s a mobile van that takes buprenorphine prescribing to the streets.
LaRochelle worries that patients, as seen in this study, are still not staying on treatment for more than a few months and are losing prime years of their lives. Some 66 percent of people in the study were under the age of 45.
“We need to reevaluate how we’re providing the care and make sure we can keep people there when they’re there,” LaRochelle said.
Even at just 3 in 10 patients, Massachusetts was likely offering better opioid medication treatment than many states as of 2014. That’s because 97 percent of the state’s residents have health insurance, the highest rate in the country. In many parts of the U.S., it’s difficult to find someone who will prescribe a patient methadone or buprenorphine.
“We just still have overwhelming stigma for patients with the disease of addiction,” said Sarah Melton, a professor of pharmacy practice at East Tennessee State University.
Volkow of NIDA is alarmed by one other finding. Thirty-four percent of patients receive at least one prescription for an opioid and 26 percent were prescribed a benzodiazepine during the 12 months after their overdose.
“This indicates that guidelines cautioning against prescribing opioids and their co-use with benzodiazepines are not being followed,” Volkow wrote.