What we miss when we focus on opioid treatment and recovery

Fortunately, there’s been growing concern that advocates, policy makers, and media have to narrowly focused on the opioid crisis. Up to this point, it hasn’t reached the level of media coverage.

USA Today is one of the first to publish an article that explores the limitations of the nation’s focus on opioid treatment and recovery:

More than eight years into his opioid-addiction treatment, Paul Moore was shooting cocaine into his arms and legs up to 20 times a day so he could “feel something.”

The buprenorphine he took to quell cravings for opioids couldn’t satisfy his need to get high. Moore said he treated himself like a “garbage can,” ingesting any drug and drink he could get, but soon enough, alcohol and weed had almost no effect unless he vaped the highest-THC medical marijuana available.

Cocaine, however, especially if it was mainlined — now that could jolt him from his lifelong depression to euphoria.

The article provides several important messages:

  • The importance of addiction treatment over opioid use disorder treatment for many (if not most) patients.
  • Along similar lines, messages about opioid recovery can be misleading for patients, families, and communities.
  • These issues raise the importance of clarity about the boundaries of recovery. For example, were these people in recovery when they were in opioid use disorder treatment and reduced or quit using opioids, but were still using cocaine and experiencing poor quality of life due to untreated addiction? (This would have been an uncontroversial and easy question to answer just a few years ago. Today, there are many saying that any movement toward wellness or participation in harm reduction is recovery.)
  • The article also highlights what gets missed when agonist treatments (buprenorphine and methadone) are described as the most highly effective and highly successful treatments without more context. They rarely answer the question, effective at what? (This isn’t saying that these medications aren’t useful or don’t have a place in care. Rather, it’s important that journalists and experts do not oversell their evidence for effectiveness.)

Failure to clarify and communicate these messages are likely to result in increased stigma for addiction and recovery.

Rather than communicating that addiction is a treatable illness, the unintended message will be that addiction more closely resembles a chronic disability than a treatable illness that has a good prognosis when the patient receives treatment of adequate quality, duration, and intensity.

This century’s first wave of recovery advocacy was built upon the message that we can and do recover when we get the right help and support. In this context, recovery meant something resembling the Betty Ford Consensus Panel definition:

Recovery from substance dependence is a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship.

The traditional understanding of addiction recovery alludes to the restoration of people in their families, communities, and to a life in alignment with their goals and values.

Adjustments to that understanding are likely to result in readjustments in the public’s attitudes, which are eventually likely to result in readjustments in policy.

NIH takes pharma dollars despite advisory committee recommendations

(Nora Feddal)

Anyone who knows me would know that crossfit.com is not a typical news source for me. In fact, when this story was sent to me, I started from a place of skepticism. However, this story about opioid manufacturers pouring money into NIH provides all the receipts.

The story explains everything clearly and provides lots of direct links to sources to support its statements. Read the whole thing.

Here’s a quick rundown:

  • The Center for Disease Control (CDC) and National Institutes of Health (NIH) both have foundations that support their work.
    • They are supposed to report who donates to the foundations, but they list many donations as “anonymous.”
    • Congress has directed them to stop listing donations “anonymous” but they continue to do so.
  • NIH has an advisory committee that issued 12 ethics recommendations about opioid industry partnerships to NIH’s director.
    • They recommended using only federal dollars (no industry dollars) in their efforts to address the opioid crisis.
    • They recommended that, if they accept industry dollars, that they not accept funding from companies involved in litigation related to the opioid crisis.
    • They also recommended complete transparency.
  • The director of NIH politely rejected these recommendations.
  • NIH has accepted millions from various manufacturers and lobbying organizations.
    • NIH’s foundation accepted a $2.5 to $5 million donation from Johnson & Johnson last year.
    • Johnson & Johnson is represented on the NIH foundation board and on a committee guiding NIH’s efforts to address opioid addiction.
    • An Oklahoma court recently found “Johnson & Johnson and its subsidiaries helped fuel the state’s opioid crisis and ordered the consumer products giant to pay $572 million.”
    • PhRMA, Pfizer and the Sackler family are also represented on NIH boards and committees.

Initiating buprenorphine treatment during short‐term inpatient ‘detoxification’

A new study on initiation of buprenorphine maintenance was just published. The press release describes the intervention as an alternative to “revolving door” detox and relapse cycles:

“patients who start long-term buprenorphine treatment at a detox program, instead of going through detox and getting a referral for such treatment at discharge, are less likely to use opioids illicitly over the following six months, and more likely to keep up treatment”

Study finds alternative to ‘revolving door’ of opioid detox and relapse

The study was recently published in the journal Addiction. Let’s take a closer look at the study.


1) What is the treatment or intervention being studied?

The researchers compared two service models in a short-term inpatient detoxification unit:

  • 5‐day buprenorphine managed withdrawal protocol and passive referral with “a full list of local substance use treatment options as well as primary medical care follow‐up options.”
  • Buprenorphine induction, inpatient dose stabilization and post‐discharge transition to maintenance buprenorphine at an affiliated primary care clinic.

2) Who were the subjects?

Subjects were recruited from a medically supervised treatment facility that provides, as usual care, evaluation and withdrawal management using a methadone taper protocol for those with opioid use disorder, along with individual and group counseling and aftercare case management. On average, patients stay for 5.7 days. The program is also associated with a methadone maintenance program and a primary care‐based buprenorphine program. Within 24 hours of admission individuals were approached by the study team, who described the study and asked permission to complete a brief eligibility screen.

“Study inclusion criteria included age 18 years or older, interested in initiating maintenance buprenorphine/naloxone treatment and willing to establish primary care after discharge with a buprenorphine provider at the nearby SSTAR health center in Fall River. Exclusion criteria included: not able to provide informed consent (due to acute illness, cognitive impairment, psychosis or not able to complete the study in English), having a history of allergic reaction to buprenorphine or naloxone, surgery in the coming 6 months, pregnancy, a current DSM‐IV diagnosis of schizophrenia, 20 or more days of use in the last month of sedative/hypnotic drugs, cocaine or alcohol (because the out‐patient program would not accept direct linkage of high‐levels of non‐opioid substance use), current suicidality, current homelessness or plans to leave the area within the next 6 months.”

3) How long was the study?

6 months.

This is good. 6 months is a relatively long-term study.

4) What outcomes did the study measure? (How did they define success?)

“Our outcomes of interest were (1) mean 30‐day rate of use of illicit opioids and (2) prescribed buprenorphine treatment days at 1, 3 and 6 months’ follow‐up.”

Treatment engagement and retention are important things to evaluation, but treatment is not recovery and may not reflect the goals of people with addiction and their loved ones.

The other outcome was illicit opioid use, which is more directly related to recovery. However, it’s worth noting that this does not include other drugs or prescribed opioids.

5) What were the study methods? What’s the quality of the evidence?

All participants completed follow‐up assessments at the end of their in‐patient stay (day 5), a week following discharge (day 12) and then at 1 (day 35), 3 (day 95) and 6 months (day 185) post‐discharge; all post‐discharge follow‐up assessments included a urine toxicology and compensation (day 12: $40, day 35: $50, day 95: $50, day 185: $50). Participants provided a urine specimen for toxicological testing (instant screens) at each assessment.

6) What did the study find?

Treatment days: By the end of the study:

  • 69% of maintenance patients were still using buprenorphine more than 10 days per month.
  • 39% were using buprenorphine on a daily basis.

Illicit opioid use: When the researches excluded missed drug screens, they found significant less illicit opioid use in the maintenance patients during the study, but these differences shrunk to non-significant levels by the end of the study.

When they treated missed drug screens as positive drug screens, the maintenance patients used illicit opioids 4-5 fewer days per month. The graphs below suggest that the maintenance patients averaged around 12 days of illicit opioid use per month versus around 16 days per month for the detox and passive referral patients.

7) Were any actual or potential conflicts of interest?

“The study medication was supplied by Indivior as an unrestricted, unsolicited grant of non‐financial support. Indivior had no role in study design; collection, or analysis and interpretation of the data; in the writing of the manuscript; or in the decision to submit the manuscript for publication.”

8) What questions does the study not answer?

Note: No study can answer all questions and any study that tries to answer all questions is likely to do so poorly. This is not meant as criticism as much as context.

  • We don’t know anything about use of prescription opioids, illicit drugs (other than opioids), or alcohol use.
  • We don’t know anything about quality of life or restoration of functioning in life domains.
  • We don’t know how this intervention would compare to a decent program. Opioid detoxification with passive referral to ongoing care is very poor care.
  • We don’t know how much (or how little) the subjects look like real-world patients. The study screened out 77% potential subjects. And, of the eligible subjects, 70% chose not to participate and another 13.5% either left the facility or were determined ineligible.
  • The researchers speculate that buprenorphine recipients benefited from protection from overdose. There were no deaths in either group, but the study did not report whether there were differences in nonfatal overdose.

NA and “understanding their reality”

I see professionals and advocates criticize Narcotics Anonymous (NA) on a near daily basis for their views on opioid agonist medications (methadone and buprenorphine), often referring to them as problematic, backwards, and complicit in the opioid overdose crisis.

The published guidance for groups is here and might be summarized as follows:

  • implying that people on agonist treatments may not be “abstinent”;
  • asserting that people on agonist medications should be welcomed in NA meetings; and
  • leaving it to groups to define “abstinent/recovery” and decide the roles people on agonist treatments can play in their group.

In the rush to condemn NA, I don’t see critics trying to understand their reasons.

This brought to mind something Isabel Wilkerson said [emphasis mine], “Empathy means getting inside of them, and understanding their reality, and looking at their situation and saying not, ‘What would I do if I were in their position?’ but, ‘What are they doing? Why are they doing what they’re doing from the perspective of what they have endured?'”


So, if we take Wilkerson’s advice (or Ta-Nehisi’s admonishment to practice a “muscular empathy”), what might we consider?

First, addicts formed NA in the context of neglect/abuse from helping systems that believed they couldn’t recover.

In a recent post, Bill White summarized some of that context:

Such treatment insults span bleeding, purging, and toxic, mercury-laden medicines in the 18th century. They include the fraudulent boxed and bottled home cures and the use of cocaine to treat morphine addiction in the 19th century. And they encompass the oft-lethal withdrawal procedures, prefrontal lobotomies, electro- and chemo-convulsive therapies, prolonged institutionalizations, and the harmful use of stimulants, sedatives, and anti-psychotic medications to treat addiction in the early to mid 20th century.

The Irrationality of Addiction Treatment

Further, many of the groups that are precursors to NA were formed in prisons.

Second, before the emergence of NA, many went to AA but were told that their needs were incompatible with AA’s singleness of purpose.

Simultaneously, another precursor to growth of NA was the experience of addict AA members who felt threatened by the overmedication (stimulants, sedatives and sleep aids) of other AA members.

So, these people who had been abandoned and abused by helping systems, whose cultural ownership had been relegated to criminal justice systems, created their own community to support each other and help others join them in their recovery.

More recently, it’s well-known that agonist misuse is common. (Professionals characterize it as instrumental use to avoid withdrawal. Patients in non-agonist residential treatment paint a more complicated story.)


Given this context, it’s not surprising that NA is relatively uninterested in the opinions of professionals telling them that they are doing it wrong. Particularly since NA members are not professionals and are simply a fellowship of people who have come together to share their path from addiction to recovery.

We might also imagine that this perceived contempt and condescension is experienced by NA members not as a 2019 reaction to a 2019 medical treatment, but as another chapter in a long history of professional neglect, abuse, domination, control, disrespect, and contempt.

Further, if groups like Medication Assisted Recovery Anonymous (MARA) were much more widely available, few would care what NA does or doesn’t do.

Given this, rather than criticize NA, a more productive use of time and energy might be to use NA as inspiration and as a model for facilitating the growth of groups like MARA. (Much like NA did with AA.)

More on that Suboxone settlement

I saw some questions about what it means. Here’s a little more context.

  • 2002 – Reckitt Benckiser introduced Suboxone.
  • 2010 – Suboxone’s patent is expiring and Reckitt Benckiser claimed that Suboxone pills present a safety hazard to children and should be pulled off the market while they introduce a new film version with a new patent.
  • 2014 – Reckitt Benckiser spins off Suboxone into a new company called Indivior.

Here’s some reporting on the implications of the settlement:

Reckitt’s settlement only covers allegations dating to the period before Indivior’s 2014 spinoff, Indivior said in a statement. Reckitt was not directly named in the feds’ criminal investigation, and prosecutors are still investigating Indivior’s own marketing of Suboxone. The company was indicted on criminal charges in April.

Fierce Pharma

So . . . that appears to be a wrap for Reckitt Benckiser.

Here’s the latest with Indivior:

The settlement partly clears the cloud of uncertainty over Indivior. The company sliced its 2019 sales forecast in half in May after the federal indictment and lower-than-expected uptake of its branded Suboxone Film. The company teamed up with Novartis’ generics unit Sandoz to roll out an authorized generic earlier this year.

However, Indivior reversed that revised guidance Thursday, announcing Suboxone’s “outperformance” in the second quarter. The company said its projected revenue on the year is now forecast between $670 million and $720 million—a 25% increase over the previous forecast—thanks to its success at preserving market share

Fierce Pharma

UPDATE: This ABC News article does a good job describing the allegations against Reckitt Benckiser.

Suboxone maker to pay $1.4 billion in largest opioid settlement in US history

From ABC News:

Suboxone maker Reckitt Benckiser Group (RB Group) will pay the U.S. government a record $1.4 billion to end criminal and civil probes into the marketing of its addiction treatment medication, making it the largest settlement related to the opioid crisis in U.S. history, authorities said on Thursday.

This would appear to be tied for the 5th largest pharma settlement ever.