The ISAM Newsletter has arrived

The recent development of a range of therapeutic options in the addiction field and translation of these into practice treatment has the potential to change the lives of our patients for the better. It is noteworthy that under the Obama presidency in the USA, a memo “Changing the Language of Addiction Treatment” was circulated to US Executive Heads of Departments and Agencies to encourage non-stigmatizing language by those bodies. While academic journals have for some time encouraged appropriate use of language it is a positive development to see government, at a senior level, follow this direction.

However, medications development and implementation also show great promise now in reducing the stigma associated with substance use problems in what is being treated and how treatment occurs.

Highly effective treatment for hepatitis C using direct acting anti-viral agents exists using genotype specific (G1: sofusbivir/ledipasvir, G3: sofusbivir/daclatisvir) and now pan-genotypic regimens, (sofosbuvir/velpatasvir) making treatment for easier to initiate by addiction specialists other specialists and generalists. Becoming HCV RNA free is a very important factor for many patients with histories of injecting drug use, not only to reduce their risk of cirrhosis and hepatocellular carcinoma but also stigma related to HCV positivity. The world of addiction treatment world needs to respond by treating patients who are HCV RNA positive in addition to accessible affordable DAA treatments for patients.

Another recent important development is the increase in programs worldwide for take-home naloxone to prevent opioid overdose. While naloxone has been available to reverse opioid overdose for decades, implementation of use by those other than medical, nursing and ambulance staff has been more recent and is a welcome development. In the USA, with a dramatic increase in prescription and heroin overdoses over the past decade, training of police in naloxone administration has now occurred in several states. Training of peers and significant others (family and friends) in using naloxone to reverse overdose has meant that now there is wide availability of this important medicine to reduce fatal opiate overdoses. The WH draft international standards for drug treatment centers recommend take home naloxone programs should be available as part of clinical treatment of opioid use disorders. Again, uptake of this effective intervention is important.

A third recent development also promises to improve the lives of patients with substance use problems. While the USA and France have adopted models of buprenorphine dispensing that does not require supervised administration of doses at clinics or community pharmacies, many other jurisdictions across the world insist on supervised administration of this medication, in the form of buprenorphine or as buprenorphine-naloxone. Indeed, some criticism of the unsupervised dosing model is that diversion of doses for non-medical use can occur, resulting in non-opiate users being exposed to the drug (albeit with reduced risks of overdose compared to many full mopioid agonists), and some users injecting a preparation not developed for IV use, with resulting injection related injuries and other harms.

Three pharmaceutical companies have been developing small-volume, long acting depot buprenorphine preparations to treat opioid use disorders. Camurus and Braeburn have developed CAM 2038, with weekly and monthly depot injections of a range of buprenorphine doses, equivalent to 8 through to 32 mg doses). Indivior (formerly Reckitt-Benckiser) have developed RBP6000, with high and low dose monthly depot injections. Both companies have completed phase 3 efficacy studies, with ongoing one year safety studies also completed.

These medications have the potential to significantly change the treatment landscape, especially in countries with supervised dosing buprenorphine models. The cost and burden of daily supervised dosing can be significant for many patients that could drastically be reduced with improvements in patient satisfaction and treatment outcomes. Depot buprenorphine treatment could reduce non-medical use of buprenorphine. It will be interesting to see how implementation of these new preparations occurs.

The combination of these factors, reducing stigma at multiple levels including at administrative levels, uptake of HCV DAA therapies, improved availability of naloxone and the new buprenorphine preparations, are all promising developments in our field.