Dr. Jonathan Watanabe: Treatments for opioid use disorder
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Fatal drug overdoses, on the rise in the United States for the last two decades, have surged even higher during the COVID-19 pandemic. The availability of medication-based opioid treatment programs has not increased apace with the growing medical need.
On Thursday, February 9, 2023, SciLine interviewed: Dr. Jonathan Watanabe, a professor of clinical pharmacy and a health-policy expert at the University of California, Irvine. He discussed topics including: regulatory, geographic, financial, and other barriers to accessing medications for opioid use disorder; need for enhanced treatment capacity for opioid use disorder; problems with the available data about opioid use disorder and treatments in the United States; the economic and social cost of opioid-related deaths; and the role of pharmacists in enhancing treatment, coordination, screening for and educating people about opioid use disorder.
Declared interests:
Dr. Watanabe serves as a member of the Forum on Drug Discovery, Development, and Translation of the National Academies of Sciences, Engineering, and Medicine. He is a distinguished fellow of the Get the Medications Right Institute. He serves on the task force of the California Health Benefit Review Program. He previously served on the Committee on Medication-Assisted Treatment for Opioid Use Disorder and, separately, The Methadone Treatment for Opioid Use Disorder: Examining Federal Regulations and Laws Committee, both of the National Academies of Sciences, Engineering, and Medicine.
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Introduction
[0:00:21]
JONATHAN WATANABE: I’m Dr. Jonathan Watanabe, and I’m a professor of clinical pharmacy and an associate dean of pharmacy assessment and quality at the University of California, Irvine, School of Pharmacy and Pharmaceutical Sciences. And I pursue research to improve health and health-related policy, and a lot of that centers on improving treatment and access for opioid use disorder.
Interview with SciLine
What is opioid use disorder, and how prevalent is it?
[0:00:49]
JONATHAN WATANABE: Opioid use disorder is a problematic pattern of opioid use that leads to clinical problems or distress. And it could also be based on factors such as unsuccessful efforts to cut down or control use, resulting in difficulties in fulfilling obligations at work, school, home, or other criteria. And about 2.7 million people in United States report suffering from opioid use disorder, which is likely an underestimate, because a lot of times diagnoses on these things do come often late, or they’re just not able to get care that does the diagnosis.
Can you provide any statistics about fatal drug overdoses?
[0:01:35]
JONATHAN WATANABE: It’s pretty frightening when you really think about the statistics about fatal drug overdoses. For the first time we eclipsed more than 107,000 deaths in the past year [that] were due to overdoses. And more than 70% of those are attributable to opioids. Most of that was due to fentanyl. And since, I think, between the period of 1999 and 2015, there was upwards of 500,000 deaths that were attributable to overdoses. And really to put that number in perspective, that’s more than the number of combat deaths in World War II. So, this is really just a silent epidemic, that really has taken an inordinate amount of lost life.
What are the economic and social costs of opioid use disorder?
[0:02:29]
JONATHAN WATANABE: The social and economic costs of opioid use disorder, they’re difficult to just simply measure, but we know many of the challenges that are presented by people that have opioid use disorder. There’s difficulty in being able to maintain work. We know that there’s some of the challenges in terms of the social consequences, in terms of injectable drug use. There’s actually a lot of other work—we want to provide better care because treatment has been associated with reductions in hepatitis C transmission, HIV transmission. Studies have shown improved social functioning. Challenges when they’re actually not able to get the care that they need actually impacts their ability to work. Many times it’s been stated as if we can improve the care that’s provided close to where they live, they’re more likely to be able to maintain employment. So, there’s manifold numbers of implications for opioid use disorder, including, I think another one that often comes up is for pregnant mothers. So, there’s—if we’re able to provide appropriate medications for opioid use disorder treatment, there’s actually a reduction in fetal and maternal outcome problems, as well as a reduction in neonatal abstinence syndrome. So, being able to provide this care it has improvements in so many different fashions for the patient—but also societally, for that some of the things I mentioned.
There are a lot of approaches to treating opioid use disorder. What works—and what doesn’t?
[0:03:17]
JONATHAN WATANABE: The name of the game is really just trying to improve access to appropriate treatment. And when things get in the way of that—and oftentimes that’s kind of been the history that that’s been associated with reductions in successful treatment, rates of retention, again, opioid use disorder, mortality, overdose deaths, all these things where if we can provide them easier mechanisms to get the care that they need, that we have seen improved outcomes. And we saw that actually a lot of these things during the pandemic—there was treatment-related measures that were relaxed to allow more flexibility in care. And we saw improvements. So, when they were able to start some of these treatments through telehealth, where they were provided more take-home doses, these things were associated with improvements in outcomes. And I think that’s translated to some of the changes we’re seeing right now to again, improve—make it easier for patients to get care that’s office-based, as well as improving the number—increasing the number of ways that patients can get care and then receive those medications at community-based pharmacies.
What kinds of medication treatments exist for opioid use disorder?
[0:05:34]
JONATHAN WATANABE: There’s three approved medications for opioid use disorder. One is called methadone. That’s the one that oftentimes you think about. It’s administered only through opioid treatment programs. Historically, those are called methadone clinics. Those entail where the patient has to go to one of these methadone clinics, oftentimes on a daily basis and receive that methadone medication. Methadone is an opioid agonist. It works it works on the same receptor as opioids, but it has basically a slower release, uptake into the into the into the body so that decreases the chances of euphoria, and it works over a longer interval. So, it’s easier to avoid the problematic patterns of opioids, and it improves the ability to treat patients that have opioid use disorder. Another medication—and this is the, the only one that can be dispensed at a pharmacy is buprenorphine. That’s a medication that’s a partial opioid agonist. So, that works at that same receptor, but it doesn’t—since it’s only partially working on that, it doesn’t generate those highs that you get from traditional opioids. And so, it decreases again and improves the ability to maintain successfully and then decrease utilization. And the third is naltrexone. That is one that actually is an antagonist at that receptor. It blocks the opioid from actually working at that receptor that’s only available in OTPs. And that’s one where you actually have to go through a withdrawal process before starting. But both methadone and buprenorphine, those can both be used prior to doing a full withdrawal. They’re actually used when you are doing a treatment withdrawal to start in the treatment process.
What are the barriers to accessing medication treatment, and what can be done to expand access?
[0:07:54]
JONATHAN WATANABE: For opioid use disorder you need to actually be being treated at an opioid treatment program—they call those OTPs or, historically, they’ve been called methadone clinics. So, that literally involves going oftentimes every day to get your dose of methadone. And so, there’s been plenty of research that has demonstrated the challenges that that represents. There was studies that have shown for some patients it takes up to 60 minutes to drive to an OTP just to get that medication. You can see how that can be a challenge if you’re trying to work, or if you’ve got children at home. So, the challenge is that places in terms of access for going to an OTP. We’ve also seen that this medication, buprenorphine, another medication, it’s the only one that can be dispensed at a pharmacy. And it can be prescribed in an office-based setting. There has historically been a lot of challenges in being authorized to prescribe it. And both the number of patients that—if you are a clinician that’s prescribing it, the number of patients that you can actually use it for, that has recently been changed in the omnibus bill in January that has removed that authorization, that wavering process as well as the cap. So, there’s been some significant changes in improving access. But that in itself—that is a very important step to improve the number of people that can be treated, but also ensuring that the medication is available at these pharmacies. Also making sure that there’s coverage and reimbursement—that this medication is actually covered depending if you’re in Medicaid, for example, if you are a pregnant woman to make sure that that your Medicaid plan actually covers these medications.
What are the limitations of the available data about opioid use disorder and treatments?
[0:10:06]
JONATHAN WATANABE: Even for CDC, sometimes the data would take more than a year to find out how we were doing in terms of the number of patients that had been suffering from opioid use disorder, the mortality data. So, it always had that challenge if you’re finding out later on how well your initiative is working, or if it’s not working. And then that presents the challenge as well. If you want to come up with a new intervention, it’s going to take you a while to find out if it’s working because this lag of the data. That’s one. Another one regarding the data is just ensuring that there is the correct counts of patients with opioid use disorder—that those diagnoses are accurate.
How are reporters doing covering opioid treatment issues?
[Posted February 9, 2023 | Download video]
