Something to celebrate?

The White House announced $1.1 for addiction treatment in the 2017 budget proposal it just introduced.

Good news, right?

Some advocacy groups are pretty excited about it, “They’re hearing us!”

If approved, here’s how the money would be spent:

• $920 million to support cooperative agreements with States to expand access to medication-assisted treatment for opioid use disorders. States will receive funds based on the severity of the epidemic and on the strength of their strategy to respond to it.  States can use these funds to expand treatment capacity and make services more affordable.
• $50 million in National Health Service Corps funding to expand access to substance use treatment providers.  This funding will help support approximately 700 providers able to provide substance use disorder treatment services, including medication-assisted treatment, in areas across the country most in need of behavioral health providers.
• $30 million to evaluate the effectiveness of treatment programs employing medication-assisted treatment under real-world conditions and help identify opportunities to improve treatment for patients with opioid use disorders.

The celebration over a budget that places such a lopsided emphasis on MAT is exactly why I am ambivalent about embracing this latest wave of recovery adovocacy.

This is a disappointment, not a victory.

The overemphasis on these particular treatments will not be good for addicts. It’s the subtle bigotry of low expectations.

Look at the actual research behind NIDA’s own advocacy for MAT.

A couple months ago, NIDA circulated an article with the headline, “Long-Term Follow-Up of Medication-Assisted Treatment for Addiction to Pain Relievers Yields ‘Cause for Optimism’”

Behind the headline

Here’s how they summarized the study’s findings:

In the first long-term follow-up of patients treated with buprenorphine/naloxone (Bp/Nx) for addiction to opioid pain relievers, half reported that they were abstinent from the drugs 18 months after starting the therapy. After 3.5 years, the portion who reported being abstinent had risen further, to 61 percent, and fewer than 10 percent met diagnostic criteria for dependence on the drugs.

These studies are important. Long-term outcomes have been a big gap in the research.

This is great news, right? 50% abstinent at 18 months! 61% abstinent at 3.5 years! Fewer than 10% dependent at 5.5 years!

Wow!

Not so fast

There are a couple of problems here.

• They were only able to do follow-up with 38% of subjects at 18 months and 52% at 3.5 years.
  • So, that 50% abstinent at 18 months is really more like 19%.
  • The 61% abstinent at 3.5 years is more like 32%

Still, 19% abstinent at 18 months and 32% abstinent at 3.5 years is pretty good, right?

Pump the brakes

There are a couple of problems here too.

• They are only reporting on abstinence from illicit opioid use, not other drugs.
• Buried in the article, they mention that they are reporting on being abstinent for the last 30 days. This doesn’t tell us much about how they’ve been doing over the previous 18 months or 3.5 years, does it?
• Same thing for the reporting on diagnostic criteria for dependence. That was also based only on the previous 30 days.

Taking their conclusions at face value

Further, their conclusions open the door to some interesting questions:

In the first study examining long-term treatment outcomes of patients with prescription opioid dependence, our results were more encouraging than short-term outcomes from POATS suggested. As reported in our 18-month follow-up study (Potter et al., 2014), and consistent with other literature (Moore et al., 2007, Nielsen et al., 2013 and Potter et al., 2013), patients with prescription opioid dependence may have a more promising long-term course, compared with expectations based on long-term follow-up studies of heroin users (Darke et al., 2007, Flynn et al., 2003, Grella and Lovinger, 2011, Hser et al., 2001 and Vaillant, 1973). Indeed, a history of occasional heroin use at POATS entry was the only prognostic indicator 42 months later, associated with a higher likelihood of meeting symptomatic criteria for current opioid dependence. Our results are consistent with research on heroin dependence in supporting the value of opioid agonist therapy for prescription opioid dependence; however, half of the follow-up participants reported good outcomes without agonist therapy.

This begs a couple of important questions.

• First, many medication assisted treatment advocates have argued that opioid addiction is unique in that it creates long-term or permanent brain dysfunction that requires opioid replacement. Do these findings undermine this theory?
• Second, half of their follow-up subjects doing well without opioid replacement. Can we assume that opioid replacement is responsible for their good outcomes?

This is the basis for the federal and media push for MAT?

It would appear so.

This not quite what you imagined when they reported 61% abstinent, is it? Why would they present it in a manner that many of us would consider misleading?

It’s also hard to understand their certainty, isn’t it?

I mean, when they talk about this being “treatment that works”, “evidence-based treatment” or “science-based treatment”, don’t most member of the public assume that expressions like “works”, “evidence-based” and “science-based” mean that there’s a body of research indicating that these treatments provide a good chance of getting well?

Instead, these studies suggest that these treatments help make people less sick.

If that’s what patients and their families want, there’s nothing wrong with that. But, they ought to know what they’re getting. (The same goes for communicating the limitations or gaps in evidence for other treatments.)

Unintended Consequences

This isn’t meant to suggest that these treatments don’t work for some people, even many people. Or, that they shouldn’t be available to addicts who want them. It’s about creating high expectations about treatments that don’t deliver as promised. (Or the evidence for their effectiveness doesn’t match the desired outcomes for most addicts and their families.)

As this plays out, I suspect recovering people and the public are going to end up feeling like they were sold a bill of goods and be more suspicious of recovery advocacy and treatment.