Abstinence-oriented treatment has taken a beating in the media recently. There have been lots of assertions that medication maintenance approaches are THE evidence-based approaches and that abstinence-based approaches lack evidence and kill addictions. We know this isn’t true and have posted repeatedly on the subject.
Right on time, Drug and Alcohol Findings reviews a recently published Cochrane report on buprenorphine vs. methadone maintenance:
Main Findings
Dosing levels were flexible in 11 studies which compared the two medications. Across these, the chances of a patient leaving treatment during study periods ranging from six weeks to a year was 17% lower on methadone. This means for example that if 60 out of 100 patients are retained on buprenorphine, had they instead been prescribed methadone, typically another 12 would have stayed in treatment. Results were similar and more consistent across the five double-blind studies in which neither patients nor clinicians were told which medication the patient was taking. Among the remaining six non-blinded studies, methadone’s retention advantage was not quite statistically significant and varied considerably between studies.
Across the eight flexible-dose studies which provided this data, numbers of urine tests indicative of continuing heroin use only slightly and non-significantly favoured buprenorphine. The same was true for the patients’ own accounts of their heroin use. There were also no significant differences in use of cocaine or benzodiazepines, though in both cases there was a slight advantage for methadone. Just two studies contributed to the analysis of criminal activity, cumulating to no significant difference between the medications.
In the fixed-dose studies which compared buprenorphine with methadone, retention was only significantly different (patients stayed longer on methadone) in the low-dose comparisons of less than 16mg of buprenorphine versus less than 40mg of methadone. In no dose range did one medication versus the other result in significantly fewer urine tests or self-reports from the patients indicative of heroin use.
Across the 11 studies which compared buprenorphine to a placebo, buprenorphine in whatever dose range retained patients better in treatment. However, only high-dose (at least 16mg per day) buprenorphine led to fewer urine tests indicative of continuing illegal heroin use.
This review looked only at retention on medication and reductions in drug use. So, the bar is set pretty low. So . . . here’s what we’ve learned from the evidence-base:
- Retention: Buprenorphine achieved a retention rate of 60% with study periods of as brief as 6 weeks and no longer than 1 year. Common sense would suggest that, if 60% is the average, the one year retention rate is significantly lower than that.
- Drug Use: Buprenorphine only reduced drug use at high doses–16mg or higher.
This is now familiar.
Researchers set the bar low and a drug therapy does not reach that bar. The solution is that the patient never stops taking the drug. The drug therapy still doesn’t reach the bar and the solution is higher doses of the drug.
First, with methadone. We shift from methadone detox to methadone maintenance. Then the evidence-base pushes higher doses.
Now, with buprenorphine. The evidence-base finds “near universal relapse” when using it as a detox tool and we’re pushed toward buprenorphine maintenance. Now, the evidence-base finds continued drug use and the solution is higher doses.
Here’s Drug and Alcohol Findings‘ summary of the comparison between buprenorphine and methadone:
. . . patients dependent on large doses of opiates may find it [buprenorphine] inadequate because there is a ceiling beyond which higher doses do not augment opiate-type effects. Patients who value the ‘wrapped in cotton wool’ feeling typical of heroin are likely to prefer methadone; those who value a clearer head might prefer buprenorphine.
I guess a clear head is relative.
On life after medication-assisted treatment (The UK has been relying on maintenance for decades and is moving away from it because maintenance patients have not been successfully re-integrating into society.):
Patients aiming for a relatively rapid break from all opiate-type drugs might do best to opt for buprenorphine initially, or to switch to it after stabilising on methadone, but have to accept the risk that instead they will drop out and return to dependence on illegal drugs.
. . . buprenorphine’s ability to help patients take a half-step away from reliance on opiate-type effects and its greater ‘leavability’ could become valued more, while methadone’s ‘stickability’ is being seen not (or not only) as a strength, but a liability. However, buprenorphine’s leavability is itself a liability if it means (as in this British study) that many more patients drop out and still only a small minority leave after successful detoxification.
The problem is that this isn’t what patients are looking for. They want their lives back. They want recovery. The evidence-base for these drugs is for reducing overdose, reducing drug use, reducing criminal activity and reducing disease transmission. They are not an evidence-based treatment for promoting recovery.
If what you want is an evidence-based treatment that’s associated with complete abstinence, low relapse rates and returning to employment, they exist and have a robust evidence-base. Health professionals and pilots have programs with outstanding outcomes. And, it doesn’t have to be expensive.
I’ll end with a reminder from a previous post about were I stand on maintenance treatments:
Just to be sure that my position is understood. I’m not advocating the abolition of maintenance treatments.
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.”
Addiction & Recovery News 
It’s a good point, that the methadone’s evidence base as a tool in recovery is lacking. The issue with the research, as you point out, is that it is answering questions around a low bar and nobody seems to have designed studies with a recovery bar in mind.
Methadone’s evidence base as a tool for recovery is as strong as for abstinence treatment: AKA, about 15-20% become abstinent, same as with no treatment, same as with inpatient rehab! There certainly have been studies that have looked at people who have come off entirely, and they find the same poor success rate as everything else. So, this is rather disingenuous.
Who said anything to defend inpatient treatment-as-usual? I didn’t and I don’t see anything from djmacuk defending it.
I specifically mentioned health professional and pilot programs, which are nothing like inpatient treatment-as-usual.
Of course, you are talking about 15-20% of a larger group, since methadone cuts death rates dramatically, so…
You said there was an attack on abstinence based treatment, which is generally treatment as usual and which is what there is evidence on, basically. So, claiming there’s more evidence for something other than maintenance is not correct: there isn’t. This is not to say that people shouldn’t have options or that there aren’t promising new approaches— but you can’t say there’s no good evidence favoring methadone for recovery but there is better evidence for something else for recovery, because there isn’t. Maintenance is the best supported treatment for opioid addiction we currently have, hence the CDC, NIH and WHO all favoring it and saying so. That’s not because of low standards— it’s because keeping people *alive* is fundamental to doing anything else!
Also, health professional programs are a red herring: they work because of the patients they select, not because they are better. If you give me all doctors to treat, I can get an 80% success rate easily because they have all the factors that tend to lead to recovery like high motivation, high education, meaningful work, relationships, money, etc. Let’s try putting a bunch of homeless high school dropouts through exactly the same program that doctors get and I guarantee you the success rate will drop to that of the other programs.
“Also, health professional programs are a red herring: they work because of the patients they select, not because they are better.”
What’s your evidence for this? Recovery capital is one variable, but doctors tend to get high quality treatment of significant duration, are linked actively to professional and generic mutual support groups and have rigorous follow-up over a long period, something their patients generally don’t get. Nurses have much poorer outcomes, yet have high recovery capital.
My point exactly: nurses have poorer outcomes because it’s not the treatment that’s the important variable, it’s people’s pre-existing resources & nurses have fewer than doctors. Simply imposing health professional programs on poor people won’t give you the outcomes you get with professionals because the program isn’t what’s making the difference & because needs are different.
I’m interested in your opinion, but more interested in your evidence. What is it?
Secondly, I don’t think I’m suggesting imposing anything on anyone, simply opening up more options for people to choose from.
I’m not familiar with studies of nurses. Are they getting the same care and having different outcomes? Or, are they getting different care and different outcomes?
Physicians have lots of recovery capital, but they also tend have very severe addictions and there’s some indication that they have elevated rates of co-occurring disorders.
I’m hearing serious and troubling class implications in your comment. Am I misunderstanding?
Are you aware of studies where other populations get that level of care, that quality of care, for that duration of time with long term monitoring and re-intervention?
Do doctors have much better outcomes for other health problems? Why this assumption that they respond so much better to treatment?
BTW – I’d never advocate for inpatient TAU. It’s bad care.
I try to be clear (maybe I fail on this count sometimes) that I’m advocating for voluntarily care that’s of adequate intensity, duration and quality, with long term monitoring and support.
Class is exactly what I’m getting at: middle and upper class people with meaningful work and higher education are far more likely to recover because they have more alternatives. Employment is highly linked with recovery, in itself. I’m not saying these class differences are good: I’m saying that if you simply put a bunch of poor people on naltrexone, 12 step meetings and heavy monitoring (which is what the physician programs basically did), you are not going to get the outcomes you get with doctors for the obvious reason that doctors have much more to lose and poor people have fewer resources, both social and otherwise, to support their recovery. Put a homeless, uneducated, isolated, jobless person into such a system without providing housing, job training and actual opportunities— you aren’t going to get outcomes like you see with PhDs and MDs with spouses, families and careers! Conversely, force a doctor into a GED program and that’s not going to be very useful either. Take this recent study comparing treatment for homeless people that was highly coordinated to treatment as usual: they found no difference http://healthland.time.com/2013/09/18/team-based-addiction-care-not-as-effective-as-experts-hoped/
Now, that result could be due to the location and the noncoordinated group may have gotten higher than usual quality care— but it’s still 40% recovering, not 80%. Even McLellan will admit that the fact that doctors are doctors has much to do with why the programs for them do so well— he just thinks that’s not the majority of the difference, but he doesn’t have any data to prove it and there are dozens of studies showing (look on PubMed for predictors of recovery) that the biggest differences in outcomes tend to be due to pre-treatment factors like SES, not treatment itself.
You’re advocating for 2 standards of care based on class?
And, you rebutt my call for a system offering “voluntarily care that’s of adequate intensity, duration and quality, with long term monitoring and support” with a study of a program that provided an average of 6 outpatient sessions?
That “highly coordinated” program offered assessment and:
To me, the real question is, why would anyone think this would be an effective intervention for very complex cases that were not even seeking treatment?
It seems to me that the only conclusions one can draw are that a model that is primary care based, low-intensity, relatively passive, is not linked to communities of recovery and only manages to deliver an average of 6 sessions over the course of a year, is not effective for homeless people with relatively severe dependence who are not seeking treatment.
That’s nothing like what I advocated. (We also provide help with the array of issues that these complex cases face–like housing, case management and help finding employment.)
And, again, I say that voluntarily care that’s of adequate intensity, duration and quality, with long term monitoring and support should be offered to every addict. If they prefer MAT, I have no problem with that. I just want informed consent that includes letting them know that doctors with the same illness get the former.
I can’t cite research, but I’d imagine that cases with greater complexity (more life problems) have poorer outcomes than less complex cases for most, if not all, chronic illnesses. I’d imagine that their compliance rates with behavioral disease management strategies are lower than less complex cases. Should there be different standards of care based on class for other chronic illnesses as well?
Who said anything about different standards of care? Nor did I rebut your call for a system that allows good options to everyone! You’ll find that nowhere in any post of mine! What I said is that you cannot claim that “treatments for doctors work better because they are higher quality” when, in fact, treatments for doctors work better in large part because they are treatments for doctors! We should provide excellent, individualized, appropriately long term care— including maintenance and abstinence options— to everyone who needs it. What we should not do is pretend that we can get rid of maintenance because “See, most doctors get better without it” and if we just offer good abstinence care to everyone which is as good as the care we offer doctors, we don’t need it. That’s not what the data suggests. The other thing that is left out of this argument is that doctors *aren’t allowed* to be on maintenance— so we don’t know if they’d do *even better* with it.
Ok. I don’t want to put words in your mouth. What I heard was this:
I understood that as advocating for two models of care base on class.
So, now, I’m hearing you say you have no quarrel with voluntarily abstinence-oriented care that’s of adequate intensity, duration and quality, with long term monitoring and support that also attends to other needs like housing, employment, etc? Regardless of class?
Right, I’m in favor of deliberately providing lousy, harmful, coercive and one-size-fits-all care for the poor and excellent, high quality, individualized care for the rich— that’s obviously a fair, unbiased and honest representation of what I’ve been saying my entire career about how wonderful inequality is and how we should force addicted people into lousy and highly damaging treatment, especially if they are poor. I completely oppose giving people options, I think only rich people should get the help they need and the poor should rot in prison, because the rich are sick while the poor are just bad. And while we’re at it, I oppose needle exchange, favor tough love to the max, want to limit access to naloxone and let’s see what else can I say that completely misrepresents my view. Are you even reading what you are writing? Of course, I support options: I simply don’t support lousy arguments that suggest that the main reason doctors do better in treatment is because they get better treatment. That might be part of it, but it’s not the main reason and failing to understand this means failing to think critically about data and about how to provide the best care. Do you think we should provide CEOs and doctors with GED programs and jobs as a required part of treatment while forcing unemployed people to “focus on recovery first” and ignoring their educational needs? I’m arguing that we tailor treatment precisely to what people need and that sometimes involves education and jobs, not just rehab. Individualize treatment for *everyone* and we’ll get better outcomes. Also, I’m not in favor of heavy monitoring for doctors or for anyone else unless you can show me it’s actually an essential ingredient for them.
I don’t understand.
That last comment was completely earnest. I had thought I understood your position and we were very far apart. Then I wasn’t sure. I was trying to say that I may have misunderstood and maybe we were much closer than I had thought.
I was trying to clarify. Not beat up on you. My apologies if that wasn’t clear or I came across as sarcastic. That was not my intent.
Yes, it sounded sarcastic to me, sorry: since I definitely wouldn’t support different quality of care based on class! It might be that class issues require certain differences in treatment to deal with those particular things (ie, someone without a GED may need one and to go to college perhaps; someone with a college degree won’t) but they should be individualized because there are obviously poor college graduates and rich high school dropouts and educational issues matter for some and not for others etc. We’re basically on the same page except you are less in favor of maintenance, it seems. I was just trying to point out that the argument about the reason the rich do better in treatment is because they get better treatment doesn’t necessarily follow. In fact, as we all know, doctors and other high SES people often get horrible care and sometimes the poor wind up with the best evidence based care because they wind up at university research centers.
I’m glad we were able to step back from that. Thanks for your understanding.
As a social worker, I work from a person-in-environment perspective.
I don’t know the evidence base for it but, I’m a strong believer that any model of care for a chronic illness, medical or behavioral, that fails to address environmental and social factors is going to have limited success and fail the more complex cases.
It sounds like we all agree on that. Of course, adding in consideration of all these variables complicates evidence-based practice.
“I’m arguing that we tailor treatment precisely to what people need and that sometimes involves education and jobs, not just rehab. Individualize treatment for *everyone* and we’ll get better outcomes. ”
Amen to that. For what it’s worth, I interpreted your post the same way as Jason, but am grateful for the clarification.