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Pill and Needles

Recommendation 2g: Availability of medications for OUD should be expanded. Even while doing so, addiction care providers should recognize that prescribing opioid agonist therapies as extensively as possible with as few constraints as possible will no more resolve the addiction crisis than it did the pain crisis.

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     The Commission recommends that opioid agonist therapy should be offered to every OUD patient where not medically contraindicated (e.g., by a medical comorbidity or potential drug-drug interaction). This should include patients who do not wish to participate in psychosocial services, as research does not clearly establish that such services are consistently necessary for patients to benefit from opioid agonist therapy.  Formal regulatory expansion of access to these medications should be considered. The COVID-19 epidemic has led federal regulators in the USA to relax some requirements currently in place around medications for OUD. These include allowing more methadone take-home doses and waiving requirements that initial buprenorphine dosing be observed in person. Such loosening of requirements is necessary in a public health emergency. When the worst of COVID-19 has passed, governments should evaluate whether the balance of benefits and risks is favorable for routinizing these emergency measures to make care more accessible.

     At the same time, recent history demonstrates clearly the folly of assuming that population health inherently improves when health care systems provide as many opioids as possible with as few possible regulatory constraints as possible. Policies which should attract skepticism include dispensing hydromorphone from vending machines to create a “safe supply” of opioids and eliminating supervision of methadone patients, i.e., converting the system to unmonitored, long-term prescriptions on a take-home basis. Although expressed from a public health viewpoint, these messages echo the opioid manufacturers in presuming that unrestricted opioid provision can only improve public health. The faith of some advocates that opioids are a “safe supply” as long they do not derive from illicit markets (e.g., heroin contaminated with fentanyl) is impossible to square with the hundreds of thousands of overdose deaths from legal, pharmaceutical grade opioids which preceded the introduction of fentanyl into North American heroin markets.

     Care providers should also consider that many patients with OUD have serious, unaddressed psychiatric, medical, family, employment, and housing challenges that a medication will not solve. Solely providing medication has generated significant resentment among some addiction recovery activists for being managed rather than treated. Opioid medications can be powerful and effective in the treatment of OUD, but should not be employed as an informal system of pharmacological sedation of poverty.