Supporting Research for Psychosocial Treatments + Medication is “sparse”

Yesterday, I told you about the new White House budget proposal for $1,100,000,000 for addiction treatment that places very heavy emphasis on medication assisted treatment (MAT).

A recently published study in Journal of Addiction Medicine, the official journal of the American Society of Addiction Medicine (ASAM), raises questions about the rationale for that budget.

That budget and it’s emphasis on MAT is based on this:

“As the Huffington Post article pointed out, we have highly effective medications, when combined with other behavioral supports, that are the standard of care for the treatment of opiate addiction. And for a long time and what continues to this day is a lack of — a tremendous amount of misunderstanding about these drugs and particularly within our criminal justice system,” drug czar Michael Botticelli said in a briefing with reporters.

You might ask, what medications are they talking about? Spend a little time following this coverage and it’s pretty clear that they are primarily talking about buprenorphine.

Let’s look at the statements, “highly effective” and “when combined with other behavioral supports”.

A recent post addressed the “highly effective” element. I’ll repeat that information below, but let’s start with the other claim, “when combined with behavioral supports.”

“when combined with other behavioral supports”

A summary of the Journal of Addiction Medicine article states:

There are three approved types of medications that work in different ways to treat people with opioid addiction: methadone, buprenorphine, and naltrexone. . . . All three medications are approved for use “within the framework of medical, social, and psychological support,” and ASAM’s guideline recommends psychosocial treatment in conjunction with the use of medications. “However,” Dr. Dugosh and coauthors add, “there is limited research addressing the efficacy of psychosocial interventions used in conjunction with medications to treat opioid addiction.”

What did they find about buprenorphine?

For buprenorphine, the results were “less robust”—only three of eight studies found positive effects of psychosocial interventions.

Of course, this is not news. Our position paper and some other posts pointed this out.

If we’ve known this since 2011, how could the drug czar and these professional reporters writing a long-form article not know?

“highly effective”

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’”

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 might be 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.

and . . .

This is a federal study seeking to determine whether adding behavioral support improved outcomes.

Think about it

The headline for the press release summary of the study is “Use of Psychosocial Treatments in Conjunction with Medication for Opioid Addiction—Recommended, But Supporting Research Is Sparse”

Recommended . . . but evidence is sparse? Let that headline sink in for a moment.

Remember that next time you hear experts or journalists refer to MAT as THE “evidence-based” treatment, or the “best hope“, or “highly effective” or a “wonder drug“.

Then, ask your self why they mentioned nothing about a model, with admittedly narrow implementation, that really does have outstanding outcomes.