14 doc • Spring 2016 Kentucky The Elephant in the Room By Tuyen T. Tran, MD Opioid addiction is an unfortunate epidemic which has recently surpassed motor vehicle related injuries as the 4th leading cause of death in the United States. In 2014, CDC reported that 18,893 deaths were related to overdose of opioid medications. And, sadly, Kentucky is the most afflicted state. (Graph 1 displays the rate of death from overdoses of prescription opioids in the United States more than quadrupled between 1999 and 2010.) These alarming trends triggered the Department of Health and Human Services (HHS) to deem prescription-opioid overdose deaths an epidemic and prompted multiple federal, state, and local actions. The objectives included 1) providing prescribers with the knowledge to improve their prescribing decisions and the ability to identify patients’ problems related to opioid abuse, 2) reducing inappropriate access to opioids, 3) increasing access to effective overdose treatment, and 4) providing substance-abuse treatment to persons addicted to opioids. Unfortunately, the most crucial objective, providing treatment to persons already addicted to opioids, was not emphasized! Opioid abuse and dependency causes a significant social, economic, and biomedical toll. Opioid substitution therapy has been proven to reduce illicit opioid use, lower rates of arrest and recidivism, decrease rates of disease transmission, and increase treatment compliance for co-occurring morbidities. The gold standard for the treatment of opioid addiction is Medication Assisted Treatment (MAT). In 2014, SAMHSA (Substance Abuse and Mental Health Services Administration) sponsored the investigation of evidence based practices (16 adequately designed Randomized Control Trials and 7 meta-analyses) specifically looking at the effectiveness of Buprenorphine. The conclusion was, “BMT [Buprenorphine Medication Assisted Treatment] is associated with improved outcomes [greater than 80% depending upon dosage and duration of treatment] compared with placebo for individuals and pregnant women with opioid use disorders.”1 The authors added, “BMT should be considered for inclusion as a covered benefit.”1 Additionally, the National Safety Council warned, while “…detoxification seems to be the most attractive [it does not involve the ongoing use of medications], in fact, this method is the least effective and may be the most dangerous [risk of overdose is extremely high].” In 2011, NIH conducted a world-wide review, specifically examining the evidence for Buprenorphine misuse. The authors concluded, “Wherever there is access to any Opioid Sales, Admissions for OpioidAbuse Treatment, and Deaths Due to Opioid Overdose in the United States, 1999-2010. Data are from the National Vital Statistics System of the Centers for Disease Control and Prevention, the Treatment Episode Data Set of the Substance Abuse and Mental Health Services Administration, and the Automation of Reports and Consolidated Orders System of the Drug Enforcement Administration.