no hint of opinion here

SecondOpinion400From an article about a new report on medications for opiate treatment:

The report also examined studies that evaluated buprenorphine, methadone, injectable naltrexone, and oral naltrexone and concluded a benefit in patient outcomes as well as costs.

“I can say with no hint of opinion here, it’s simple fact, they are all effective,” McLellan said. “They’re effective not just in reducing opioid use, they’re effective in so many other ways that are important to societies and families.”

Effective. It’s a fact. No opinion here. Hmmm.

Effective at what? These drugs are effective at reducing opiate use. If that outcome is all one wants, they may be a good option.

The problem is that it’s a palliative response, when we know that full recovery is possible if the right resources are made available. (Of course these treatment approaches are not the ones physicians choose for themselves and their peers.)

Let’s see what the report says about another outcome that might speak more directly to quality of life, say, employment [emphasis mine]:

These studies have also measured various types of related outcomes such as reductions non-opioid drug use, employment and criminal activity. Here the literature is quite mixed and appears to be a result of the particular patient population, the clinical approach of the methadone maintenance program and the available counseling and social services provided.

and

As with methadone, the literature is quite mixed with regard to reducing non-opioid drug use, improving employment and reducing crime.

and

He also found improvements within the methadone maintenance group across various time periods on HIV risk behaviors, employment and criminal justice involvement. [My note: In this study, employment increased from approximately 21% to approximately 31%*.]

So…while there’s little doubt that these medications reduce opiate use and overdose deaths, the quality of life evidence is considerably weaker.

With the increases in opiate ODs, I understand families and individuals struggling with these decisions. I struggle to come up with the best analogy for informed consent. Maybe something like this?

Maybe the choice is something like a person having incapacitating (socially, emotionally, occupationally, spiritually, etc.) and life-threatening but treatable cardiac disease. There are 2 treatments:

  1. A pill that will reduce death and symptoms, but will have marginal impact on QoL (quality of life). Relatively little is known about long term (years) compliance rates for this option, but we do know that discontinuation of the medication leads to “near universal relapse“, so getting off it is extremely difficult. The drug has some cognitive side-effects and may also have some emotional side effects. It is known to reduce risk of death, but not eliminate it.
  2. Diet and exercise can arrest all symptoms, prevent death and provide full recovery, returning the patient to a normal QoL. This is the option we use for medical professionals and they have great outcomes. Long-term compliance is the challenge and failure to comply is likely to result in relapse and may lead to death. However, we have lots of strategies and social support for making and maintaining these changes.

The catch is that you can’t do both because option 1 appears to interfere with the benefits of option 2.

CORRECTION: This post originally stated that the Anglin study found an increase in employment from 21% to 21%. It has been corrected to 21% to 31%.

UPDATE: I added the following to option 1 –  but we do know that discontinuation of the medication leads to “near universal relapse“, so getting off it is extremely difficult.

19 Comments

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19 responses to “no hint of opinion here

  1. Ben Scharf

    I like to say that I was on methadone 9 years and if you don’t plan on quitting heroin or illegal opiates that methadone is the way to go. There are plenty of benefits of being on it. Right now i have over 6 years clean and sober but in my earlier days when i was young and no way giving up all drugs i was at least able to work and have a somewhat normal family life. The only thing i had to do was go to the clinic once a day and actually actually thought that doing anything but that was in my head wrong. Now if i would of put therapy and meetings like 12 step who knows that might of worked on me more to eventually get off of it quicker.If your not using heroin that means your not breaking into anywhere or shoplifting or robbing to get money to use. You can actually hold a job and pay your one time payment a week that is a heck of a lot cheaper than the other way. So your not only saving money yourself your saving the public money because you’re no longer stealing or ending up in the hospital from a o.d.I don’t recommend anyone stay on it as long as i did because eventually like for me at the end even a max dose wasn’t holding me.

  2. That’s a great example, Ben, thanks for sharing your story.

    There is a very recent study out of Finland that links opioid replacement therapy with a significant decrease in criminal justice involvement: 97% drop in conviction rates, 95% drop in property crime rates, and 94% drop in overall crime rates among participants. Here’s a breakdown of the study with links to the journal article: http://alltyr.com/http/wwwmattsubblogspotcom/2013/6/16/proof-that-enrollment-in-opioid-substitution-programs-is-linked-to-decrease-in-criminal-convictions

    I get that you are ideologically opposed to opioid replacement therapy, but I know too many people who are living full, happy, productive lives with jobs, family, and friends (including a 4.0 gpa graduate student) to agree with your “palliative” opinion. Not to mention, while it shouldn’t be the most important aspect driving treatment, the public health benefits cannot be denied.
    When treated with the right dosage, opioid-dependent patients do not experience cognitive cognitive deficits and are able to live full lives like anyone else. The more we inject ideology into this issue the more likely it is that kids will ignore a valid option, relapse, and overdose/die. Let’s focus on the science, not the ideology. It’s a great option for lots of folks (not all, but definitely lots). What’s more, there has never been a study that showed abstinence-based treatment to be more effective than maintenance.
    Hope everyone is enjoying their weekend

    • You accuse me of being ideologically driven and ignoring science when I am citing ASAM’s own pro-medication report and the studies it cites? Then you resort to anecdote for evidence that I’m being ideological? (You did the same thing last time with PHPs.)

      You also cite head to head studies and use the phase “more effective” without telling us, “effective at what?” Please share all of these head to head studies and the overwhelming quality of life science you intimate exists. If it existed, one would think ASAM would have cited it in its pro-medication report. (I’ve repeatedly ceded that the evidence on crime and disease transmission is strong.)

      I’ve offered my own stab at informed consent that wrestled with the benefits of ORT and offered some citations. Why not take your own stab at it instead of taking cheap shots at me?

      Finally, you suggest that science guide us. The problem with that is that science can only provide data for the questions we ask. It doesn’t offer meaning and context for that data. People have to look at the available data, determine the relevant contextual factors and determine the meaning of the data and what to do with it.

      Your comments are approaching troll territory. I welcome comments with differing opinions, but comments that repeatedly debate straw men, attack persons rather than arguments, and fail to even acknowledge difficult questions for their POV will be treated as trolls. (Or spam, when they include links back to their business’ website.)

      This blog does have a point of view. It’s openly acknowledged throughout it. It’s based on science and experience. And, while I have strong opinions, I’m willing to cede that reasonable people can disagree and engage their strongest arguments.

      • Whoa, now, “troll” is a pretty serious term. I feel strongly that ORT is important and that it far too often receives a bad rap. Your statement that it doesn’t improve QoL is purely anecdotal – many would suggest that fewer opioid-positive UAs would be a QoL improvement in itself. Here are a few of the most important studies on the topic I know of. I stand by the fact that abstinence has never been shown to provide better outcomes – no matter how it has been defined scientifically. I apologize for offending – I didn’t mean to come off that way. I just have only ever seen you write about ORT in less-than-supportive terms, but I have only been reading your blog for a couple months. I hope we can still be allies – and continue this conversation. These are a few of the studies I know of:
        Painkiller abuse treated by sustained buprenorphine/naloxone, November 8, 2011 News Release – National Institutes of Health (NIH)

        http://www.drugpolicy.org/docUploads/meth347.pdf

        http://www.evidencebasedpracticenetwork.net/Documents/Methadone_maintenance_therapy_review.pdf

        http://www.cdc.gov/idu/facts/methadonefin.pdf

        http://www.who.int/substance_abuse/activities/methadone_essential_medicines.pdf

        Survival and cessation in injecting drug users: prospective observational study of outcomes and effect of opiate substitution treatment | BMJ

        kimber et al. chance of death drops 10% for each year on ostSurvival and cessation in injecting drug users: prospective observational study of outcomes and effect of opiate substitution treatment | BMJ

        Buprenorphine tapering schedule and illicit opioid use

        Caldiero et Inpatient Initiation of Buprenorphine Maintenance vs. Detoxification: Can Retention of Opioid-Dependent Patients in Outpatient Counseling Be Improved? – Caldiero – 2010 – The American Journal on Addictions – Wiley Online Library

        http://www.lac.org/doc_library/lac/publications/MAT_Report_FINAL_12-1-2011.pdf

        williams Cellular and Synaptic Adaptations Mediating Opioid Dependence

        Acker, C

        Buprenorphine for the treatment of op… [Am J Health Syst Pharm. 2007] – PubMed – NCBI

        Adjunctive counseling during brief and e… [Arch Gen Psychiatry. 2011] – PubMed – NCBI

        woody et JAMA Network | JAMA | Extended vs Short-term Buprenorphine-Naloxone for Treatment of Opioid-Addicted YouthA Randomized Trial

        http://www.methadonesupport.org/dole_nyswander_1967.pdf

      • oops. I copy-and-pasted and some of those links didn’t come through. Here are the ones I missed:
        http://www.nih.gov/news/health/nov2011/nida-08a.htm
        http://www.bmj.com/content/341/bmj.c3172
        http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3150159/
        http://onlinelibrary.wiley.com/doi/10.1080/10550490500418989/abstract
        http://physrev.physiology.org/content/81/1/299.full (discusses the permanent nature of neurological changes due to prolonged opioid abuse)
        http://www.facesandvoicesofrecovery.org/pdf/White/StigmaMedicationTreatment.pdf (interesting paper regarding the stigma associated with maintenance and strategies to reduce it)
        http://www.ncbi.nlm.nih.gov/pubmed/17244875
        http://www.ncbi.nlm.nih.gov/pubmed/22065255
        http://jama.jamanetwork.com/article.aspx?articleid=182827

        Again, no condescension intended in my original reply – just a sincere, if poorly worded, note about ORT.
        I like your informed consent analogy, but diet and exercise only work in a small fraction of people – vs nearly 50% in ORT.

      • All of your citations speak to reducing drug use or treatment retention. I’ve ceded that ORT reduces opiate use, disease transmission and OD risk.

        I don’t see where these references speak to quality of life. I’m familiar enough with the literature to know that the ASAM report pretty accurately captured the weakness of the QoL evidence. You cite Bill White. He has become a pretty passionate advocate for ORT being on the treatment menu (I’ve said multiple times that I have no objection to it being an option.) and he cedes that the QoL evidence is weak.

        Regarding, “the permanent nature of neurological changes”: Again, as I asked in a previous exchange, if opiates make permanent neurological changes that make drug-free recovery unlikely, why do physicians, who go undetected for long periods of time and tend to use higher doses, recover in such high numbers?

        What you say diet and exercise work for a small fraction, a few questions. What does “work” mean? What are you basing that on and what kind of treatment? (I’ve argued that most drug-free treatment is not provided with the appropriate quality, intensity and duration. So, I’ve pointed to PHPs for a model of effective chronic disease management.) Same thing about ORT, what does “work” mean?

        I got a little riled, maybe too riled. But this was a post that attempted to deal with the strongest arguments for ORT and discuss how patients might evaluate the benefits and costs of each option. To accuse me of a kind of blind ideology that will lead to death in my patients is the kind of thing that riles a person.

        I’ve got no problem with patients being able to make an informed choice. My problem is that they don’t get the information they need to make an informed choice and, even if they get that information, most people don’t have access to care of the appropriate quality, intensity and duration.

      • Jason
        This debate (at least for me) has always been about more than just your, or my, clients. I am sure you offer incredible, above-average quality treatment at Dawn Farm. What worries me is the other large number of programs who offer no ORTs, no informed consent, and barely adequate diet and exercise regimens. It is my worry that they will read your intelligent criticisms of ORT, go over to read Anna David and Russel Brand, and say, “I’ve done my part – if you don’t get well here it’s because you didn’t try hard enough”. Hence, my eagerness to comment.
        As far as the PHP study you frequently cite – I think it’s a prime example of hypocrisy that the industry would hold its members to a different standard; but it is a good example of the power of longitudinal, open-ended care.
        Regarding QoL, a quick lit search only produced evidence of QoL improvements for patients on maintenance. The only mixed results I saw were that, for people on MMT in a couple studies, the QoL improvements were greatest within the first month or two of treatment. The QoL still improved, just not as significantly. I found one study referring to the impact of MMT on QoL as “ambivalent”. Still, one out of a dozen or so (on a cursory glance) is hardly mixed.
        I again refer to the larger picture – you’re right, far too many people do have access to the appropriate level or quality of care. In the meantime, people who are offered average ORT vs average TAU tend to do much better (on the standard measurements). This is and has always been my point. Most people are getting average care, which, in general, is improved with the addition of ORT.
        Hope you have a great day.

      • On QoL, I already shared the comments on employment outcomes from ASAM’s forceful pro-ORT report.

        Here’s what Bill White had to say on empirical knowledge about QoL and methadone [emphasis mine]:

        Methadone maintenance treatment has been evaluated using two broad benchmarks: 1) changes in behaviors that generate harm and costs to society (e.g., crime, disease transmission, unemployment, abuse/neglect/abandonment of children), and (as in the evaluation of other treatment modalities) 2) the percentage of clients who maintain abstinence or no longer meet diagnostic criteria for opioid dependence following discharge from treatment.

        The first benchmark reflects legitimate public health concerns, although it is noteworthy that these have been collected and emphasized at the exclusion of measures of the effects of MM on personal/family recovery (including measures of global health and quality of life). As a professional field, we know a great deal about what methadone maintenance treatment can eliminate from the lives of patients, but we know very little from the standpoint of science about what it adds. In fact, we know very little about the stages and styles of long-term medication-assisted recovery. It is regrettable that information on long-term MM-assisted recovery has not been collected and used to shape a menu of stage-specific recovery support services.

        Keep in mind that this was in his forceful pro-MMT advocacy piece.

        About ORT vs. TAU, what does “much better” mean? What measures? Illegal opiate use? Illegal drug use? Criminal convictions? Housing? Employment? Physical health? Self-reported QoL? Marital status and child custody?

        TAU is typically once a week outpatient and is terribly inadequate.

        Cochrane said, “there are no trials comparing methadone maintenance treatment with drug-free methods other than methadone placebo trials, or comparing methadone maintenance with methadone for detoxification only.” I’d like to see your ORT vs. TAU (or abstinence-based treatment) references.

  3. Ian and Ben,

    A few thoughts about your comments.

    First, I’d begrudge no one their individual path to recovery. Whatever works.

    Second, Ben, I’m glad you were able to transition to something that has given you the quality of life you wanted.

    Third, there’s no doubt that methadone reduces crime and disease transmission. The problem is that the data on quality of life is much weaker.

    Fourth, ORT programs have migrated away from the use of methadone and buprenorphine to gradually transition patients into drug-free recovery. Most providers only offer long-term maintenance. (I bring this up in reference to Ben’s use of ORT as part of his path to eventual drug-free recovery.)

    Finally, I have no interest in forcing anything on anyone. I just want a system of care where everyone is offered accurate and complete information and the same hopeful and high quality care that physicians themselves receive. If they choose another path, I have no interest in obstructing their pursuit of recovery and I’ll celebrate any success they enjoy.

    All the best,

    Jason

  4. Lucida

    “The catch is that you can’t do both because Option #1 appears to interfere with the benefits of Option #2” – unfortunately, this is accurate for several reasons, but the hope is – it doesn’t have to remain that way!

    1) Buprenorphine is very good at reducing or eliminating opioid withdrawal symptoms. The linked article in your other blog (“not available”) questions whether other options for treatment/recovery don’t appear to work for those on ORT because “people on opiates opt out of life.” There’s evidence that this medicine Suboxone in particular works so well that people (including providers who’ve only received a paltry 8 hours of training) mistake the absence of use/withdrawal as recovery. There is little motivation to engage in additional recovery supports, at least from a physical standpoint. But the social, emotional, legal and family consequences still exist and can be a motivating force.

    2) The 12 step community as a whole does not welcome people on Suboxone with open arms. They are at times told- and more disastrously, treated as if- they are not sober. At least one transitional housing program in the nation instructs its residents not to tell anyone they are on Suboxone. Other transitional housing programs disallow it altogether. What if the recovery community decided to withhold contempt prior to investigation on this matter? The truth is, we don’t know how people would do given both Option 1 and Option 2 because it hasn’t been tried. This saddens me as it doesn’t take away anything from the strength of the fellowship to give it a try. The same attitude was taken towards psych meds in the fellowship 30 years ago. AA withstood that.

    Thanks for the thoughtful post.

    • Thanks for the thoughtful comment Lucinda. It will be interesting to see what this all looks like 5 or 10 years down the road. Couple of thoughts on your points.

      1) The findings that buprenorphine patients didn’t benefit from counseling we from an apparently large and well-funded study, that I would imagine addressed the real-world concerns you raise.

      2) There’s a lot of truth to what you say about the 12 step recovering community. I have two thoughts. First, I think they have good reason to wary of new medications. We’ve seen lots of “safe” medications and “treatments” over the years, only to discover that they are very problematic for recovery. (Benzos, for example.) Second, There’s truth in what you say about psychotropics, but I find that this is often overstated. I entered 12 step recovery nearly 23 years ago on 3 psychotropics and I was instructed to make sure I informed my doctor of my addiction and follow her direction. And, I got sober in something akin to a back to basics group in a recovering community that was not especially progressive.

      Thanks again. All the best, Jason

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