Treating the Opioid Epidemic

If one deterrent to opioid abuse is a healthy dose of personal connection, perhaps everyone should meet Jonathan Watanabe. The associate dean of pharmacy assessment and quality at UCI’s School of Pharmacy & Pharmaceutical Sciences is warm, self-effacing and quick to laugh, even while engaged in the serious business of eliminating barriers to treatment of opioid use disorder.

Watanabe earned a doctorate in pharmacy at USC in 2007 and a doctorate from the University of Washington’s Comparative Health Outcomes, Policy and Economics Institute in 2012. He was named in 2021 to the National Academies of Sciences, Engineering and Medicine committee that examines federal policies around methadone treatment for opioid addiction. A renowned expert in health policy, Watanabe was appointed to the NASEM Forum on Drug Discovery, Development and Translation in 2019 and serves with other University of California faculty on the California Health Benefits Review Program Task Force, advising legislators on proposed health-related bills.

He came to UCI from UC San Diego in April 2020, excited about the campus’s multidisciplinary healthcare model. He directs the School of Pharmacy & Pharmaceutical Sciences’ Center for Data-Driven Drugs Research and Policy, which aims to improve healthcare access, affordability and inclusion.

UCI Magazine contributor Cathy Lawhon talked with Watanabe about his passion for increasing the availability of opioid use disorder treatment.

How do you define opioid use disorder, and what are its effects?

Opioid use disorder is defined as a problematic pattern of use that leads to clinical adverse effects. From 1999 to 2015, upward of 500,000 overdose deaths were reported in the U.S. – more than U.S. combat deaths in WWII. The problem is rife and growing. Life expectancy in the nation has dropped every year for the last four years, and OUD is one reason. Other effects are long-term cardiovascular damage, maternal mortality that peaks postpartum, neonatal abstinence syndrome, and increased hepatitis C and HIV transmission. And there are economic effects of lost work.

How do current treatments (methadone, buprenorphine, naltrexone) work?

Methadone and buprenorphine function at the same brain receptors as opioids but are much less likely to lead to problematic euphoria. They allow people to get off opioids without going through withdrawal. With time, they can stop the treatments. Naltrexone blocks opioids, so patients go through withdrawal. Treatment must be fully medically supervised.

How and why has opioid use grown in the U.S.?

The Centers for Disease Control and Prevention has reported that 2.7 million U.S. residents suffer from opioid use disorder, and that’s an underestimate. When people who have depression and anxiety are isolated, they’re unable to get help for their distress, which allows things to spiral. Isolation got out of control during the pandemic. It’s important to remember that addiction is a chronic brain disorder protected under the Americans with Disabilities Act. It’s nothing new, yet we make people jump through hoops for treatment we wouldn’t require for any other chronic disorder.

“It’s important to remember that addiction is a chronic brain disorder protected under the Americans with Disabilities Act. It’s nothing new, yet we make people jump through hoops for treatment we wouldn’t require for any other chronic disorder.”

What kind of hoops?

Traditionally, one could only get methadone for OUD at an opioid treatment program. You’d have to go daily for a single pill, and that’s not simple because there are only about 1,800 opioid treatment programs in the U.S. People could live 100 miles from a program. With buprenorphine, until recently, clinicians had to apply for a waiver to prescribe it, and they were limited in the number of people they could treat. One study showed that if everyone eligible for a waiver obtained one and if they treated all the patients they were allowed to treat, they still couldn’t meet the need.

Are these barriers coming down?

Federal legislation this year eliminated the waiver. Anybody licensed to prescribe opioids can now prescribe buprenorphine in a regular clinical setting. COVID-19 ushered in changes too. You don’t want people traveling 100 miles in a pandemic to wait in line in the cold. Opioid treatment programs increased take-home doses to seven to 14 days, or they prescribed through telemedicine. There was little to no abuse found in drug screenings.

What else can be done to treat OUD?

Emergency rooms are where the battle is waged. ER doctors stabilize overdose victims, but immediately starting treatment in the ER is an afterthought. We need to change that. Also, mobile methadone clinics could improve access to treatment in the homeless population, where overdoses are spiking. We need to prepare the future workforce for research and development that decentralizes clinical drug trials and makes them more community-based. I’m co-chairing a committee for the National Academies to spur that effort on.

The Food and Drug Administration recently approved over-the-counter sales of naloxone (a nasal spray to reverse the symptoms of opioid overdose). Are you encouraged?

Yes. In these policy discussions, some are more conservative and don’t want to change treatment access too quickly. But in the end, we have to acknowledge that the current system is not working. With naloxone, we’re not trying to make it easier for people to use opioids. It’s harm reduction. I use EpiPens as an example. We don’t make them available to encourage people with peanut allergies to eat more peanuts. They save lives.

Do you have time for hobbies?

I don’t have time, so I make a hobby out of something I would do anyway. I cook. I grow herbs and vegetables, and I love Italian cooking because all I need is good San Marzano tomatoes and herbs.

What’s the best advice you ever received that informs your work?

I grew up playing hockey, and one principle I learned was to skate to where the puck is going – not where it is now but where it’s going to be. I came to UCI in part because the College of Health Sciences has a grand plan to integrate pharmacy and pharmacology sciences into multidisciplinary care. That’s the workforce of the future. That’s where things are going.