Buprenorphine + therapy = ?

Red_Drug_Pill---recoveryIan McLoone directs us to another study (the 4th in a row) finding that buprenorphine patients receive no benefit from added behavioral treatments.

Where does this leave us?

We’ve seen criticism of the devolution of methadone maintenance (MMT) into dosing clinics with calls for a new recovery orientation to MMT and a return to methadone being one element of a comprehensive bio-psycho-social treatment program.

I’m also reminded of this quote from a methadone advocate:

All chronic diseases have a behavioral component, and that’s what you’re dealing with—a chronic disease. The problem with the methadone community is we have too many people who think methadone is a magic bullet for that disease—that recovery involves nothing more than taking methadone.

This view is reinforced by people who, with the best of intentions, proclaim, “Methadone is recovery.” Methadone is not recovery. Recovery is recovery. Methadone is a pathway, a road, a tool. Recovery is a life and a particular way of living your life. Saying that methadone is recovery let’s people think that, “Hey, you go up to the counter there, and you drink a cup of medication, and that’s it. You’re in recovery.” And of course, that’s nonsense. Too many people in the methadone field learn that opiate dependence is a brain disorder, and they think that that’s all there is to it. But just like any other chronic medical condition, it has a behavioral component that involves how you live your life and the daily decisions you make.

If opioid replacement therapy (or medication-assisted treatment) should be more than just taking medication, and the medication appears to interfere with the effectiveness of the behavioral treatments*,  where does that leave us? What is it about the drug that interferes? (Earlier this week I posted a link to a study the found blunted emotional responses in buprenorphine patients. Previous studies have found impaired cognitive function.)

Also, keep in mind that the drug use outcomes this study focused on were 3 consecutive negative drug screens, 6 consecutive negative drug screens and the average number of negative drug screens. These outcomes measures tell us something, but these are not the outcomes that addicts and their families will measure their success by. At the same time, subject satisfaction rates with buprenorphine were very high. (85%)

How can you build a recovery-oriented treatment model, when the patient is somehow rendered immune to our other tools?* Will they benefit from mutual aid? Does whatever’s going on impact quality of life?

I’ll also throw in a reminder from a previous post about were I stand on ORT:

Just to be sure that my position is understood. I’m not advocating the abolition of methadone.

Here’s something I wrote in a previous post: “All I want is a day when addicts are offered recovery oriented treatment of an adequate duration and intensity. I have no problem with drug-assisted treatment being offered. Give the client accurate information and let them choose.”

Another: “Once again, I’d welcome a day when addicts are offered recovery oriented treatment of an adequate duration and intensity and have the opportunity to choose for themselves.”

It’s also worth noting that there is a link between AA and methadone.

* See this point discussed in the comments below.

6 thoughts on “Buprenorphine + therapy = ?

  1. Thanks for the share, Jason!
    There’s just one statement in your post that I’d like you to elaborate – that “the medication appears to interfere with the effectiveness of the behavioral treatments”. I’m not sure that I see that in the literature. The way I understand it, these studies challenge the conventional wisdom that counseling improves ORT outcomes. However, none of the studies I have seen suggest that either have a detrimental effect on the other – simply that counseling doesn’t seem to add additional benefit.
    I could definitely see counseling providing benefits in terms of basic needs and crisis intervention – a relationship with a counselor could improve the likelihood that someone gets access to housing, food, etc.Although I haven’t seen these issues addressed in the aforementioned studies.
    Thanks again!

    1. You know, I thought that the evidence for CBT for opioid dependence was stronger than it is.

      I see your point.

      Here’s what I was thinking: CM is known to reduce drug use. However, it doesn’t reduce drug use for patients on buprenorphine.

      What’s that about?

      I suppose it comes down to which is more effective and whether the other creates a floor effect? Obviously, that would be a very difficult thing to demonstrate.

      I suspect we’ll see more buprenorphine used among health professionals. This will be the opportunity to see how buprenorphine affects outcomes in a recovery-oriented system of care.

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