Jeffrey Samet: What is the problem with the term “beds”? To a member of the public, increasing the number of beds available to people with Opioid Use Disorder (OUD) probably sounds like a good thing.

Peter Friedmann: The term “beds” is associated with inpatient and residential care.  In the commentary, we have argued that the solution for people with OUD is not more inpatient care beds, but more access to effective outpatient medication treatment slots.

JS: The inpatient care you mentioned may involve drug-free or “abstinence-only” treatment. In the US, states often seek to increase the funding available for drug-free treatment, and we see court-imposed attendance of 12-step programs. Is this a problem?

PF: For most addictive disorders it is not a problem, for example courts ordering a person with alcohol use disorder to attend AA. But opioids are a special case first, because we have effective medications and second, the loss of tolerance resulting from “abstinence-only” treatment puts the person at high risk for overdose death. The current epidemic of opioid overdose deaths makes it imperative that all such persons be offered pharmacotherapy as first line treatment.

JS: How often do people in abstinence-only treatment relapse? Is losing tolerance really more dangerous than detoxifying?

PF: For people with OUD, relapse is very common during or after abstinence-only treatment.  The process of withdrawing the opioid, i.e. detoxifying, leads to the loss of tolerance.  Once detoxified, the opioid receptors are no longer “down-regulated” (that is, accustomed) to the high doses of opioids, so if someone relapses to anywhere near their previous “dose” of opioid use, they can stop breathing and die.

This is especially problematic for people using street opioids, because when you buy a bag of heroin you don’t know what dose you are getting.  Nowadays, you don’t even know that you’re getting heroin – in many cases you’re getting fentanyl which gram-for-gram is 50 times stronger. With medication treatment, the opioid receptor is occupied and “blocked” making it more difficult to overdose upon relapse.  In the case of the agonist treatment (that is, methadone or buprenorphine)  the person retains their tolerance and even if they stop the medicine and use, they still have some protective tolerance to opioids, making overdose less likely.

JS: So what can be done to move away from treatment-free approaches and towards pharmacotherapy? And who’s responsible?

PF: The question of who’s responsible is not the right question going forward, in my opinion. We already know many of the things that work to reduce opioid overdose death — so the right question now is “why are we not doing them?”

Clinicians need to be more careful in prescribing opioids, and counsel our patients to properly dispose of any unused medication to limit their non-medical use.  We should make naloxone, the agent for reversing overdose, as ubiquitous as Band-Aids in peoples’ first aid kits, and teach patients and families how to recognize overdose and intervene.

We should eliminate the stigma associated with medication treatment of OUD, and come to view long-term treatment with buprenorphine or methadone for OUD as we do insulin for diabetes or beta-blockers for heart disease.  We should make such treatment a routine part of every primary care practice, and reimburse these clinicians appropriately.  For folks with OUD who are not ready for treatment, we should engage them in safe use practices through syringe access and other harm reduction programs, and provide safe venues for supervised use where personnel are trained to recognize overdose and administer oxygen, life support measures and naloxone where necessary to save a life.

Who is responsible for seeing to it that these things get done?  That is the role of policy, a function of government.  It falls to the government to implement an adequate national response for a crisis of this scope.