Excessive certitude abound

photo credit: kennymatic

photo credit: kennymatic

UPDATE 2 (12:15 on 11/8/15) – A few hours ago, I posted about a pulled Huffington Post article that questioned parental rights for people on opioid replacement medication. In the original post, I failed to explicitly say that I strongly disagree with this position. It’s an awful thing to say. I should have made this very clear, at the top of the original post.

However, my post was not really about this extremist argument questioning parental rights of ORT patients. I’d rather not draw attention to such an extremist argument. Rather, my post was about the article getting pulled.

While making this extremist argument, Richard Taite pointed to research findings of  high relapse and mortality rates in ORT patients. Rather than make the case that Taite’s position is extremist and rebut his evidence, there was a call for the article to be retracted. Why not deal with his best arguments? Especially if one believes that they are so easily refuted.

Buried under his judgment and extremism are two important questions:

  1. Are the benefits of ORT frequently overstated?
  2. In aggregate, what are the strengths and limitations of each treatment approach for quality life for the patient and their families?

Recent coverage of the issue paints anyone who raises these kinds of questions as out-dated, moralistic, simple-minded and one-wayers. Some coverage comes close to implying that anyone who questions ORT is enabling overdose deaths. It’s frustrating.

Below is the original, unedited post. I thought about pulling this post because I don’t want any appearance that I endorse Taite’s position, but I decided to keep this post up because it raises important questions about the evidence base and the  degree to which differing opinions are tolerated. (After all, it was an opinion piece. And, if Huffington Post pulled every goofy opinion piece, they’d be pulling a lot of content.)

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This morning, I sent some friends a link to a Huffington Post article about Suboxone and methadone, mostly because I thought some of the links within the article might be of interest.

Unfortunately, the article was pulled from Huffington Post. I have no idea if this is related, but a Huffington Post writer tweeted that the article was trash and received a response from another writer asking if it could be retracted or “corrected.”

One of them suggested that the writer had a conflict of interest and was making false claims about his competition. (That the author is the CEO of a treatment program was at the top of the page. Apparently, opioid replacement medication is “the competition.”) The other wrote an epic longform article on opioid addiction and treatment that framed medications as the best hope for opioid addicts and, despite its length, completely failed to mention the extremely effective treatment model that is used for opioid addicted health professionals, lawyers and pilots.

Honestly, I would have never posted about the pulled article. I know nothing positive or negative about Cliffside Malibu, but I tend to be suspicious of Malibu treatment centers because the area seems to be a hub for shady boutique programs and I try to avoid drawing attention to anyone that might be sketchy.

Fortunately, the pulled article is available at PsychCentral.

It isn’t especially remarkable. It expresses common concerns about opioid replacement treatments (ORT). It makes a few arguments that I might not have made. However, unlike a lot of opinion writing, it provided links to research to support its points.

It argues that the benefits of ORT are overstated. For example, one of the links in the article is to a study of Suboxone with the following results:

Results
A total of 220 participants were included in the study. The age range of participants was 18–67 years with most being African American males. Eighty-three (38%) remained in the study for at least 1 month, with 37 of the 83 (45%) remaining in treatment for >3 months. Ten of the 37 (27%) never relapsed after their longest period of abstinence from heroin. During the first year after initiating treatment with Suboxone, hospitalization and emergency room visit rates for all 220 participants decreased by 45 and 23%, respectively, as compared to the year prior to starting treatment. The number of legal charges for drug possession decreased from 70 to 62. Anecdotally, the quality of life seemed to improve in those who were treated with Suboxone for longer periods of time and received regular counseling.

You’d imagine that these outcomes would be pretty disappointing, right? If I understand correctly, the reported outcomes are as follows:

  • 62% drop out by day 30.
  • 83% drop out by day 90.
  • 95.5% relapse.
  • Possession charges dropped by only 11%

Did they express surprise and disappointment at their findings? I mean, these outcomes are only good if we are extremely pessimistic about the prognosis for this patient population, right? (Though, note that it keeps providing percentages of smaller and smaller segments of subjects rather than percentages of all of the 220 subjects.)

No, they weren’t disappointed. Here’s their conclusion, “Overall, Suboxone is an effective treatment method for heroin addiction and is a viable outpatient therapy option.”

The pulled article also linked to a study of 12 year follow-up of methadone treated parents. (Note that this kind of long term follow-up is important and rare.)  That study’s findings included the following:

Mortality among the addicted parents was high. Thirty-two (25%) of the 130 families experienced the death of the addicted parent, and in 2 cases both parents had died before the long-term follow-up interview (34 deaths total). For comparison, mortality in the general population of Washington State was 7.5% 25 in 2005 and 14.8% among heroin users in the Seattle metropolitan area.

Methadone is often cited for it’s effectiveness in reducing mortality. There’s no doubt it reduces mortality. However, I’ve previously noted that this benefit seems to be overstated. This study seems to offer another piece of evidence for this view.

So this guy expresses his opinion in Huffington Post (a publication that seems to be largely opinion) and supports his opinion with evidence. Then, rather than respond to his evidence two writers discuss retracting or correcting the article? I’d have thought writers would have a more free press philosophy and responded to ideas/information they don’t like with better ideas/information. And supporters of abstinence-based care get framed as “one-wayers”?

I have no idea if this twitter exchange had anything to do with the article being pulled, but it’s unfortunate that Huffington Post has repeatedly presented a one-sided view of the issue and then, when it finally posts a different view, it gets pulled within hours.

UPDATE 1 (9pm on 11/7/15): Just to be clear. I’m not questioning whether an ORT patient can be a good parent. The question is, in aggregate, what are the strengths and limitations of each treatment approach for quality life for the patient and their families?

I’m not interested in stigmatizing any addict. My most recent post on the topic of MAT said this:

It makes me sad to hear of anyone doing the deal feeling shame about being a recovering addict.

People with opioid addiction ought to have access to methadone, if that’s what they want. Without shame.

They also ought to have access to the gold standard for addiction treatment—the same care that an opioid addicted health professional gets.

They also ought to get accurate information about the various pros and cons of each approach.

For example, they ought to know that the gold standard demands a lot of the patient, and existing models have relied on using the health professional’s license as a contingency to maintain compliance with these demands. They also ought to know that the approach hasn’t been studied on the general population of opioid addicts because no one has been willing to invest in it.

They also ought to know that despite all of the arguments that research proves “methadone maintenance is the most effective treatment for opioid addiction”, the evidence base for methadone focuses on reduced drug use, reduced OD, reduced criminal activity and reduced disease transmission.

Bill White, a researcher and methadone advocate, summarizes the evidence this way: “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.”

In other posts, going back to the beginning of this blog, I’ve repeatedly said things like:

“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.”

“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.”

4 Comments

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4 responses to “Excessive certitude abound

  1. Recoveringnurse

    just so you know those health care professionals that get the gold standard treatment…. Have to pay for it themselves. An average of $400 per month for 3 – 5 years. If you don’t stay sober and complete the program the state takes your license to practice. There’s kind of a lot at stake and a big time as well as money investment.

  2. “The reported outcomes are as follows:
    62% drop out by day 30.
    83% drop out by day 90.
    95.5% relapse.”

    Disappointing results by any measure, and the fact that nobody addresses the poor outcomes brings to mind ‘The Emperor’s New Clothes’. The way the percentages were reported from the research almost seems wilfully deceptive. Now if people really were offered informed choice, they ought to be told of these outcomes before being prescribed.

  3. My biggest problem with the post was this guy being held up as “expert” in mental health and addiction science despite zero credentials as such. Sorry to say, but the days when being in recovery was the only credential necessary to be an expert in addiction are over.

    I appreciate your view of opioid agonist therapies, but this guy’s piece was not offering even a fraction of the critical thought that you’ve given this topic. In fact, he calls recovery with medications “half-baked recovery” and suggests it is somehow less than, despite hundreds of thousands – if not, millions – of stories that prove otherwise.

    Also, are you aware of the controversy associated with the so-called “gold standard” treatment approaches used in PHPs? There are numerous professionals who feel strongly that the system is broken, and uses coercion, intimidation, philosophically-based approaches that have led to a rash of physician suicides. See this recent Medscape article for some of the coverage: http://www.medscape.com/viewarticle/849772

    If everybody was offering open-ended, high quality, comprehensive and long-term substance use disorder care, then the arguments against agonist therapies would be more easily swallowed, IMO. It’s just that the standard of care that results in 28-day spin cycle rehabs is not a fair alternative, though it’s the only alternative for far too many experiencing opioid use disorder.

    I, too, long for the day. I hope we see it soon.

    • I know nothing of the guy and, like I said, I tend to be skeptical of boutique programs. So, I have no real interest in defending him. This felt like censorship to me, and that bothered me.

      I’ll take your word for it that he has no credentials, but he did present some evidence to support his (extremist) position. It bothers me that I’ve seen no response to the evidence he shared.

      As for PHPs, I’m aware that they are being criticized and that most of this is around coercion. Clearly, any implementation of that model with other populations would omit coercion and there are legitimate questions about what omitting coercion would do to their outcomes. However, for many patients, using restoration of a role/identity that provides deep personal meaning as a tool for initial and ongoing engagement seems like an element other models should adopt.

      I don’t know how common abuse is, or what kind of additional oversight might be appropriate. If abuse is not rare and oversight would not interfere with patient safety, I have no objection to additional monitoring. However, I’m not sure how relevant these is to a proposal to offer a treatment model based on PHP model on a voluntary basis.

      The linking of a rash of suicides to PHPs without any evidence of a rash of suicides, let alone a relationship to PHPs, troubles me.

      We can agree that too many patients have to choose between lousy drug-free treatment and lousy MAT.