Comment; Dr. Volkow has done a great job reviewing the multi-faceted approach the current administration is taking to resolve the opioid epidemic
by Dr. Nora Volkow | Nov 12, 2018
This past spring, Congress added $500 million to the fiscal year 2018 budget of the National Institutes of Health to accelerate the search for scientific solutions to the opioid crisis. Using these resources, the Helping to End Addiction Long-term (HEAL) initiative engages several NIH institutes on two priority areas:
(1) enhancing pain management with the aim of preventing opioid addiction and overdose while improving pain treatment and
(2) improving the treatment and prevention of opioid use disorders (OUD).
The latter goal, significantly led by the National Institute on Drug Abuse, includes not only developing improved treatments for OUD (medications and behavioral interventions) but also the development of new models of care to expand access to treatment through healthcare and justice settings, including rural populations, and new strategies to prevent OUD.
Treatment providers currently have three FDA-approved medications to treat OUD, as well as one newly approved medication that can treat physical symptoms of opioid withdrawal (lofexidine). There is also naloxone, an opioid antagonist drug that can reverse opioid overdose, which is available in different formulations. Patients with OUD and those at risk of overdose due to chronic pain treatment with opioids would benefit from a wider range of options tailored to individual needs and circumstances.
Some of NIDA’s HEAL initiative research dollars are being invested in research to develop new formulations of existing medications such as depot formulations of opioid agonists and longer-acting naloxone formulations or more potent opioid antagonists capable of reversing fentanyl overdoses. New therapeutic approaches are also being investigated, such as compounds that target non-opioid receptor systems to control opioid withdrawal symptoms and cravings and immunotherapies that would prevent the drug from entering the brain. The goal of the Focused OUD Medications Development Research Project is to conduct high-impact studies resulting in around 15 Investigational New Drugs (INDs) and ultimately the submission of around 5 New Drug Applications (NDAs) to the Food and Drug Administration (FDA).
With HEAL money, NIDA also doubled the budget of its National Drug Abuse Treatment Clinical Trials Network (CTN), which facilitates collaboration between our Institute, university research scientists, and community treatment providers in the development, testing, and implementation of new addiction treatments. By adding new sites and new investigators, the CTN Opioid Research Enhancement Project will significantly expand the CTN’s capacity to conduct trials. In addition to enabling the expansion of studies already underway, the funds will also facilitate the development and implementation of new studies aimed at improving treatment engagement and retention in general medical settings such as emergency departments, obstetrics/gynecology, pediatrics, and primary care and at establishing strategies for intervening in the early stage of OUD.
Compounding the tragedy of the current opioid overdose epidemic is that proven prevention and treatment interventions exist but are simply not being adopted and implemented effectively in communities and populations that could most benefit. For example, a growing body of research shows that better delivery of OUD treatment to people in the justice system could have a huge impact at reducing rates of overdose among newly released prisoners as well as improving other outcomes like treatment engagement after discharge. Thus, a portion of the HEAL funds will be used to create a network of researchers studying how to improve access to evidence-based addiction treatment in justice settings and upon release from prison or jail. The Justice Community Opioid Innovation Network will survey addiction treatment services in local and state justice systems across the nation, gathering data on the adoption of medications and other factors, as well as outcomes, with the aim to ensure that interventions in justice settings have the highest possible impact.
Even in the wider population, the availability of services is extremely low: Only one in five people with OUD receive any care, and fewer than half who receive care get medications. To find ways to surmount the many barriers to treatment and demonstrate the effectiveness of attacking the problem on multiple fronts, NIDA is partnering with the Substance Abuse and Mental Health Services Administration (SAMHSA) to launch pilot projects on integrated evidence-based interventions for OUD in up to three communities heavily impacted by the opioid crisis. In the communities targeted by the HEALing Communities Study, an integrated collection of evidence-based prevention and treatment interventions will be implemented within healthcare, behavioral health, justice systems, and community organizations, with the goal of reducing opioid overdose deaths by 40 percent within 3 years of implementation. As part of this goal, the projects will seek to reduce the incidence of OUD, increase the number of patients receiving medications, increase treatment retention and the receipt of recovery support services, and expand naloxone distribution. It is hoped that the results of this bold initiative will yield best practices that can be translated into other communities.
Of course, the projects funded by the HEAL initiative are only a portion of NIDA’s work to find solutions to the opioid crisis. In addition to the kinds of research mentioned above, NIDA is also working to improve the availability and quality of addiction and pain treatment through our comprehensive clinician outreach, NIDAMED program. Through this program, physicians can access, among other resources, current evidence-based materials to integrate into their practices. One example is the newly launched “Science to Medicine” series, the first topic of which shows how six clinicians integrated medication treatment for OUD into their practices. ASAM has been a trusted and vital partner to NIDAMED, and NIDAMED supports ASAM efforts like Addiction Treatment Week.
The opioid crisis is a daunting challenge for addiction medicine specialists and for healthcare as a whole. But I am encouraged to see such support and commitment from all levels of government as well as the private sector in joining forces to meet the challenge. ASAM members are already at the forefront of efforts to counter the opioid crisis, and by setting an example for compassionate, evidence-based care for people with OUD, they are instrumental not only in helping address the current opioid crisis but also in helping to prevent future addiction crises.