2012′s most popular posts #3 – Hazelden to start opioid maintenance

This has gotten a lot of attention [emphasis mine]:

…for the first time, Hazelden will begin providing medication-assisted treatment for people hooked on heroin or opioid painkillers, starting at its Center City, Minnesota facility and expanding across its treatment network in five states in 2013.  This so-called maintenance therapy differs from simply detoxifying addicts until they are completely abstinent. Instead, it acknowledges that continued treatment with certain medications, which can include some of the very opioid drugs that people are misusing, could be required for years.

What’s their case? [italics mine]

The science, however, is getting harder to ignore. Studies show that people addicted to opioids more than halve their risk of dying due to their habit if they stay on maintenance medication.  They also dramatically lower their risk of contracting HIV, are far less likely to commit crime and are more likely to stay away from their drug of choice if they continue maintenance than if they become completely abstinent.

The first 3 points are not in dispute. Maintenance does reduce risk of overdose, contracting HIV and committing crimes.

However, the last point makes it sound like people put on maintenance are less likely to use heroin than people in drug-free treatment. In truth, she’s referring to the fact that once people are put on maintenance, there was “nearly universal relapse” when researchers tried to taper them off the drug.

Why opiate replacement?

“For most people using opioids daily, they are no longer getting high, even when they are still using.  It’s just become maintenance,” Seppala says. The effect is similar to the tolerance people experience with caffeine.  “If you drink caffeine on a daily basis, after a while, you don’t notice the effect of one cup of coffee,” he says, “But if you drank two, you would.”

Really? They weren’t getting high before they entered treatment? It’s like coffee?

Ok, moving on, but why do they think maintenance is a good idea for opiate addicts?

…with opioids, there is no significant mental, emotional or physical impairment if someone  regularly takes the exact same dose. In fact, research shows that patients addicted to opioids who are on maintenance doses of anti-addiction drugs like buprenorphine can drive safely, work productively and engage emotionally like those who aren’t addicted.

This isn’t our reading of the research. For example, the data on driving is mixed, at best.

On the issue of emotional engagement, the data doesn’t look too convincing either. Further, we know that opioid addicts benefit from talk therapy based addiction treatment, UNLESS they are on buprenorphine.

How long will patients be on the drug? [emphasis mine]

Hazelden will start using buprenorphine maintenance cautiously at first.  The drug will not be provided to people who have been addicted to opioids for less than a year and complete abstinence will remain the ultimate goal for most patients, even as the program recognizes that years or even lifetime maintenance on the drug may sometimes be needed.

Keep in mind, that there’s more than a little money involved:

If an addict is fully informed and wants buprenorphine, I have no objection. But this is a terrible direction for the field to take. As we’ve pointed out before, opioid addiction is relatively common among health professionals, we DO NOT treat them with opioid maintenance, they get 12 step and abstinence oriented treatment and they have great outcomes.

Read our position paper for more on why Dawn Farm does NOT use opioid maintenance treatment.


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