In 2010, addicts' drugs-of-choice are often found in a bottle with a child-safety lid and a local drug store label. That's the take-home message repeated in reports from local and national public health officials and drug enforcement agents.
Since there are medicine cabinets in SoHo lofts, west Texas cabins, Tampa condos, as well as trailers in Appalachia, the epidemic of opioid-based prescription painkiller abuse knows no boundaries.
But while the disease is ubiquitous, the options are limited: go cold turkey or travel daily to a clinic for methadone -- which is why addiction researchers continue to search for innovative ways to treat not just heroin addicts but also patients addicted to OxyContin, Vicodin, and Percocet, to name a few.
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An emerging strategy is treatment with buprenorphine, also known by the brand names Subutex and Suboxone, for treating patients addicted to any type of opioid.
It's a fairly new approach to fighting the disease -- not just because it has a novel mechanism of action, but because it can be prescribed by a primary care doctor.
The concept of filling a prescription for opioid treatment rather than sending patients off to a specialty clinic is a compelling notion to those faced with the big numbers of addiction.
Since its approval in 2002, buprenorphine has increased access to addiction treatment -- but only incrementally, as addiction experts say barriers to wider deployment still exist. Among those barriers are insurance companies that refuse coverage, as well as an undercurrent of apprehension about the rigors of treating addicts in the primary care community.
"We have a raging epidemic of addiction, and the most effective treatment is buprenorphine," said Dr. Andrew Kolodny, a psychiatrist who specializes in addiction medicine at Maimonides Medical Center in Brooklyn, N.Y. "How long will [patients] have to suffer before they have better access to this treatment?"
Researchers have been working on some solutions, including telemedicine and a website that matches patients with primary care doctors who are willing to treat opioid addiction -- but lessons from the past suggest that change will not come quickly.
Since the mid-20th century, methadone has been the workhorse of opioid addiction treatment. It's a full agonist, which means it gives users a slight rush -- albeit one that is not as potent as heroin or other opioids.
A patient typically goes to a clinic once a day for a dose and can stay on daily methadone for years. Though clinics are fairly common in urban areas, they can be hard to reach for those in rural areas. And researchers say the rigors and social stigma of seeking treatment at a methadone clinic can be a barrier to care regardless of locale.
On the other end of the treatment spectrum is the much less commonly used naltrexone (ReVia), an opioid antagonist approved in the 1980s for opioid addiction. But this drug is used more commonly to treat alcoholism -- an indication granted in 1995.
It acts as a shield, completely blocking the brain's opioid receptors so that users can't get high no matter what they try.
"A full opioid agonist is a key in the ignition," said Dr. Petros Levounis, director of The Addiction Institute at Roosevelt and St. Luke's Hospitals in New York. "You put it in, the car goes 100 miles per hour."