Widespread Ideas for Widespread Treatment

Dr. Chapa:
Welcome to Clinician’s Roundtable on ReachMD. I’m Dr. Hector Chapa, and I recently had the chance to speak with Dr. Joshua Lee, who’s the Director of the NYU Fellowship in Addiction Medicine. Here’s a snippet of our conversation focusing on our country’s battle against opioid use addiction.

Dr. Lee:
Well, we thought we were turning a corner and we're not turning a corner. So, we did finally have a plateau and dip, I think, in 2018 of total overdose deaths per year and opiate-related overdose deaths. But from ‘17 to ‘18, it looked like we finally had enough, you know, treatment availability and healthcare access and preventative messaging, and maybe as drug epidemics do, the opiate epidemic was kind of burning out in some communities that had already been so hard hit for decades now. And then in ‘19 and we think in ‘20, amidst COVID, things have just gotten worse again, and probably due to the now wide availability of fentanyl and fentanyl-like analogs like carfentanil in the heroin and oxycodone supply. So primarily people want to use heroin or oxy, and now more and more if you are getting heroin and oxy, you're also getting fentanyl.

And that's some recent study data we have in a study we did in New York City. Most of the urine samples of people who are actively using, they’re buying, you know, bags of gray powder on the street that everyone agrees is heroin. And then you test the urine and they usually do have heroin in the urine and also fentanyl. And fentanyl, of course, is that much more toxic, hard to use, deadly; the growth curve in overdoses is due to this fentanyl contamination. And that used to be less widespread, and now it's all over, just like heroin used to be available mostly, you know, in Baltimore and New York, and now you can get it anywhere. That means we're nowhere near the end of this. We're right in the thick of horrible, kind of national problem. And it really has not been getting better.

So I think the good side of that is it'll keep the pedal to the metal in terms of federal and state level responses, encouragements for more doctors to get their X-waiver, or to get rid of the X-waiver at the top. And then the rest of us can start prescribing more freely for the development of new treatment products. Opiate use disorder is exquisitely well treated through medications as opposed to counseling. So the way it works is it hits the mu receptor and gets it used to opiates. And that's really hard to overcome. But if you use these medications like methadone, buprenorphine, or naltrexone, a different approach, but, you know, you can either use opiates themselves or these opiate antagonists. Either way, you can get really nice, good outcomes as long as people are taking those medications. So it really becomes about availability, access, scaling up. But the good news has always been we have great treatments as opposed to like depression, where if we had a national epidemic of resistant depression, like we sometimes don't have great treatments for a widespread chronic condition like that.

And with opiates, it doesn't mean people are going to do great and have great outcomes because they've got to stay on treatment. And that can be a struggle. And that's where, you know, support, counseling, kind of wraparound services can be crucial. That's always been kind of the good news. And we'll see if we can develop, you know, even better mousetraps or new drug candidates that can slip into the mu opiate receptor and prevent, you know, essentially fentanyl use. 

But, you know, in the here and now, I'm not going to predict the epidemiologic curves, but it's not great stuff right now. And COVID is probably made it worse, as with other substance use, people are probably drinking more, smoking more, we're all stressed out. We all are going crazy in our houses, and the heroin supply out there is actually fentanyl and it's super dangerous and people are still using it. And thus, we still have a huge problem on our hands.

Dr. Chapa:
I just thought of something, you know, specifically in medical education programs, residency programs,  we're affiliated with a medical school here, we have a lot of underserved or non-insured patients that are on public assistance, you know, state insurance or federal insurance. Is that covered by public insurance? Is MAT, is that a possibility for the otherwise uninsured patient?

Dr. Lee:
Yeah, generally it is, although you can get into a red state, blue state, Medicaid expansion, non-ACA divide. But the ACA itself did a ton to make MAT more accessible. That was always a part of it. And to, of course, give people more health insurance. So I'm sitting in New York State where for years now we've had, you know, not 100 percent, but 90 plus percent of people insured. Everyone with insurance, including able-bodied men who are eligible for Medicaid in our state, can get treatment and can get these medications and can get these medications without a lot of hassles like prior authorization. Now, that may not be the case in Texas, where I'm not licensed, I don't work, and I couldn't tell you exactly how it works. But other states, particularly, you know, red, Sunbelt, Southern states, have been a lot tougher in terms of access, coverage, availability, and really stigma, where there's been more of a kind of disincentive or movement against some of these medications, including buprenorphine, despite the horrible opiate epidemic in Tennessee. Like Tennessee has famously over the last couple kind of state health cycles done some things that make buprenorphine even less accessible to your average Tennessean. But it really is a state level issue in terms of Medicaid availability period, and then what Medicaid covers, and then how behavioral health and addiction treatment services are covered and then whether or not these OUD medications are easily accessible and reimbursed.

Dr. Chapa:
That was Dr. Lee talking about some of our country’s progress and setbacks in the battle against opioid use addiction. I’m Dr. Hector Chapa, and to hear my full conversation with Dr. Lee along with other episodes in this series, visit ReachMD.com/Clinician’s-Roundtable, where you can Be Part of the Knowledge. Thanks for listening!