Should maintenance be the first-line treatment?

Canada1

A recent article in Substance Abuse Treatment, Prevention, and Policy takes a look at the role of maintenance treatments in Canada.

A recent report in the Lancet (2012) concluded that “research into the treatment for [PO] addiction has been chronically neglected. As a result, the evidence base that informs best practice is thin […] The ‘standard treatment’ for [PO] dependence is evolving, and [there is no] single current standard at this time” [10]. Yet, current Canadian treatment system realities seem to suggest the opposite. In Ontario, Canada’s most populous province (~13.6 million pop.), the number of individuals enrolled in methadone maintenance treatment (MMT) has skyrocketed to just under 50,000 in 2014 (from a mere 3000 in 1996, and 29,000 in 2010), with the vast majority of recent enrollments presumed to be PO-related.

Maintenance as the first-line treatment

Not only has MMT enrollment skyrocketed, it’s become the first-line treatment for all stages and types of opioid dependence–not just late stage, treatment-resistance cases.

The above data reflect that OMT – mostly with methadone but some suboxone-based in exceptional cases – has proliferated as the de facto first-line treatment for PO-related disorders in Ontario. This is despite the fact that OMT is designed as long-term – in many cases for life – pharmacotherapy for most patients [18]. The predominant reliance on OMT for PO-disorder treatment is mainly based by research evidence from long-term heroin users, even though substantial, clinically relevant differences between heroin and PO users are documented [1923]. Furthermore, this practice has evolved largely in the absence of an evidence-based stepped-treatment model for PO-disorders, even though evidence exists for benefits of treatment options less intrusive (and potentially less costly) than MMT.

It’s worth noting that this is the direction that that our own government wants to go.

How did Canada’s treatment system get to this point?

While the pharmaceutical industry’s corporate greed and tactics have been popularly blamed – and legally punished – for the PO abuse epidemic (e.g., [32, 33]), economics within the health care system appear to exert an un-desirable dynamic in the realities of treatment for PO disorders. In addition to standard reimbursement for OMT care within Ontario’s public fee-for-service-based health care system, the province introduced additional financial ‘incentives’ in 2011 to entice more community physicians and pharmacies into MMT delivery [34, 35]. In this context, an extensive proliferation of numerous ‘for-profit’ MMT-only clinics occurred focussing on economies-of-scale – i.e., large patient numbers – yet also featuring treatment quality problems (e.g., compromised patient care, inappropriate take-homes or “carries”, excessive urine testing) [3638]. While the MMT-focussed incentives have created a proliferation of MMT clinics and patients in Ontario, there has been no commensurate investment in short- or mid-term treatment interventions, for example with abstinence, where possible, as a main goal for potentially suitable patient sub-groups. While these treatment interventions may potentially be more care effort- or management-intensive in the acute treatment phase, they be less costly for the system – yet also provide less income for OMT providers or medications producers – in the long run.

Again, our government is moving in the direction of major investment and incentives to expand maintenance treatments.

Are the authors “one-wayers”?

No.

Allow us to be perfectly clear: Our position is not ‘anti’-OMT for PO-disorders. In fact, several of the present authors have actively argued for the expansion of OMT availability in Canada when this was still a highly restricted and scarce treatment for the treatment of opioid disorders not so long ago [15, 40]. We believe however that OMT’s proliferation as the first-line-treatment for PO disorders has been propelled to excess by several of the wrong reasons . . .

Why not maintenance as a first-line treatment?

You might ask, “What’s wrong with an aggressive approach?” Well, the writers point to adverse effects that are not mentioned in US policy discussion and advocacy.

While OMT undoubtedly brings therapeutic benefits to many opioid-dependent people, and is the best available therapuetic choice for a large sub-group of patients with PO disorder it also implies the continued exposure of patients to potential correlated adverse effects (e.g., brain structure changes, depression, mortality) of chronic opioid intake – risks that should be minimized especially with young and non-severely dependent patients [4550]. Long-term OMT should thus surely be an available treatment option in a continuum-of-care, but primarily for non-responders to less intrusive alternatives where these seem reasonably indicated as a first treatment option.

7 Comments

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7 responses to “Should maintenance be the first-line treatment?

  1. Liz

    Well said Jason. This is a fear of mine, we go to a one-way treatment approach. I was reading the updated suboxone literature that is provided to prescribers of that medication and it talks about a holistic treatment that should be applied with that medication. Individual therapy and group therapy, CBT, close Doctor monitoring, urine testing to see if the right dose is being taken and if other drugs are being taken with it. It’s a whole continuum of care. The most important thing I read was that a person should be tapered down over a person of months until they are abstinent. Suboxone isn’t being marketing as a life time treatment. It’s a stepping stone. Unfortunately, unless the doctors are monitored, I’m afraid that’s exactly what will happen.

    I hope we don’t look back 10 years from now and realize we made a grave mistake and once again we’ve been duped by big Pharma and their “evidence based treatment.”

    • Unfortunately, the push in recent years has been for long term maintenance. (Though few people use the expression “life time.”)

      That shift came in 2010 after the big federal studies tried to use Suboxone as a stepping stone, but reported, “In persons dependent on prescription opioids, tapering with buprenorphine during a 9-month period, whether initially or after a period of substantial improvement, led to nearly universal relapse in the National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study.” (http://www.medscape.com/viewarticle/722342)

      Further, assumptions about there being an additive benefit (from adding psychosocial treatments to buprenorphine) appear to be wrong. (Despite of the drug czar repeating it over and over.) JAMA recently published a meta-analysis on opioid replacement medications plus psychosocial interventions and reported, “there is limited research addressing the efficacy of psychosocial interventions used in conjunction with medications to treat opioid addiction.” And, “For buprenorphine, the results were ‘less robust’—only three of eight studies found positive effects of psychosocial interventions.” (https://addictionandrecoverynews.wordpress.com/2016/02/05/supporting-research-for-psychosocial-treatments-medication-is-sparse/)

  2. I’m not sure what your statement above means: “Further, assumptions about there being an additive effect appear to be wrong.” (I don’t know what an “additive effect” is, I guess.)

    Also, I just came across the UK/european prescriber info. There are some super interesting differences in the way the manufacturer recommends using this drug in the UK compared with the US. In particular, take a look at “initiation therapy” and “less than daily dosing.” http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/000697/WC500058505.pdf

    • What I meant was the assumption that there would be some benefit to adding psychosocial interventions to buprenorphine. It’s intuitive to assume that adding more treatments will result in better outcomes, but it doesn’t appear hold water.

      That less than daily dosing seems like it would be more likely to cause sedation and euphoria.

  3. Ronnie Tyson

    OMT must be combined with outpatient treatment and recovery supports because clients become mostly psychologically and physiologically dependent on opioids based OMT. In a recent outpatient collaboration with primary care and long-term partial antagonist patients psychological dependence was a barrier to recovery initiation. Therefore OMT as frontline therapy outcomes would be improved with full antagonist therapy and minimally recovery supports. Clients psychologically dependent may also benefit from outpatient therapy

  4. I feel like I’ve faced one addiction after another my entire adult life none as bad as heroin. I spent so many years in prisons and jails I was convinced it would be something either I would take to my grave…or it would take me to the grave, most likely the latter. Finally after more than 20 years of that I began taking methadone, to make a very long story shorter I was saved. I never, and I do mean never used again. I’ve got about 18 years of clean drops, I’m on the top level as far as take homes. I believe there are those that want it to work, are truly tired and want to have a better, (productive) life, and there are those that don’t. As they say, ‘you can’t save the everyone’ sure you will have failures. Not every methadone clinic has dopers hanging out selling drugs, if there are, they should simply arrest them or put them off the clinic. People do that stuff because no one stops them. The treatment must be offered to those that want/need treatment. It’s a lot cheaper for MMT than to continue jailing people. It works for those that let it work. I know I’m not the only person that takes it and has changed my life for the better. They need to stop spending so much time worrying about when they can get them clean…that’s not for any court or judge or anyone to say, the person may never get off, but what’s the alternative…force them off, and the cycle starts again…maybe this time though they don’t make it. Authorities need to stop thinking they know better that the addicted person or the addicted persons doctor. It needs to be offered with no dosage limits and no limit on how long you need it. Does medicare/medicaid tell the diabetics that their insulin will only be covered for 2-3 years…no they don’t, but they feel it’s ok to dictate those limits on methadone. When some of those things change it will be easier to find/get treatment. A medical treatment is given until the treating doctor says you are well. Start treating us for what we are…patients not dope fiends.

    • I’m happy that you’ve found success.

      You and I are in complete agreement that no addict should be jailed for possession and that all addicts should get good informed consent and have access to the MAT or the physician health program model.