A closer look at the evidence (Part 4)

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This is the 4th post in a series taking a look at the evidence provided by advocates of medication-assisted treatment (MAT).

If you haven’t seen the other posts in the series, you can find them here. (part 1part 2 and part 3)

This post reviews some of the lessons from a closer look at the 19 studies in the meta-analysis provided by Newt Gingrich, Patrick Kennedy & Van Jones.

What have we learned?

We’ve learned a few things:

  • The subjects in these studies often do not resemble the general population of treatment seekers. They are often pregnant, lower severity or misuse only prescription painkillers.
  • The design of these studies often provide contact with research staff 3 to 5 times per week. Some even used monitored dosing.
  • Even with these non-representative populations, retention ranged from around 30% to 65%, with most of those study periods being 16 weeks or less. There were a few with retention rates as high as 75% over a year. Those studies were in Sweden, with unusually intensive treatment or integrated into essential medical care.
  • There was very little attention to abstinence. In the few studies where abstinence was mentioned, the outcomes were not good–relatively low percentages achieving abstinence for periods of 3 to 12 weeks.
  • Ongoing drug misuse is the norm among the subjects in these studies.
  • If you want to look at apparently effective models of MAT, go to Sweden. (Their studies included very high levels of monitoring, support, contingencies and services to address housing, employment and other needs.)

 

The pitch from Gingrich, Kennedy and Jones sounds very similar to many other advocacy pieces.

I don’t have any problem with advocacy for MAT. It can reduce harms associated with opioid addiction there are problems with access in rural areas. However, I do not understand how people like Gingrich, Kennedy and Jones can reconcile what the research actually find with this statement [emphasis mine]:

Medication assisted treatment, or MAT, is the use of FDA-approved medicine in concert with behavioral counseling for opioid addiction that has proven efficacy. Multiple studies have shown that MAT is essential to effective long-term recovery, by reducing cravings and the risk of fatal overdose and increasing abstinence and time in treatment. And we have known this for a long time.

These advocates oversell the benefits of MAT and will eventually undermine public confidence in treatment and the belief that opioid addiction is a treatable condition.

If I was a person seeking treatment for opioid addiction, I’d feel misled by the information they provide. For example, their statement “in concert with behavioral counseling” is diametrically opposed to the findings in the paper they share as evidence. Further, the paper does not provide any evidence for MAT as a path to abstinence. In fact, the paper suggests abstinence is rare among MAT research subjects.

Advocating for MAT is fine, but please give an accurate picture of the evidence and, given the limitations of MAT, inform readers about the kind of treatment doctors provide to their peers with opioid addiction.

 

2 Comments

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2 responses to “A closer look at the evidence (Part 4)

  1. Jason, we have been using “abstinence only” before I got sober in 1980, with horrendous results. We ran ranch residential, hospital based, outpatient and a brief stint at the Florida Model. None, gave us an outcome rate better than 5%, so we checked outcomes from our colleagues at the Betty Ford Center. There’s was no better and we began to believe that the problem was that opiate dependent patients were “flawed, different” from our other patients who had much higher rates of recovery. Keep in mind, France was using buprenorphine, with tremendous results for years with heroin addicts. We didn’t know anything about it, until 2004, and began to research the studies that we could find and began a trial group to see if we could increase retention and enhance outcomes. Immediately, our retention moved close to 90%, while outcomes increased dramatically. In eleven years, we have never had a current or former patient overdose on opiates. We treat an average of 60 patients in primary care (IOP, PHP or amb. detox). I know that you will find many flaws in my explanation of events, however, we were staunch advocates of abstinence only for 25 years, prior to opening our eyes.
    You repeatedly, use the Airline pilots Assn. as a model for the average American. Let’s see what is different in that treatment model. Number one, the patient is highly educated and has a tremendous amount to lose, if they fail to adhere to all aspects of the program. They are, also, given an indefinite period of paid leave to treat their addiction, which often lasts for a year or more. We have had many pilots in our program, so I am very familiar with their protocol. They do, get the very best treatment services for an indefinite period of time, and rightfully so, but do you really think, that any other program, is going to have the same resources allocated to their treatment while carrying the same leverage to tangibly motivate their continuation and compliance with program goals?
    MAT is here to stay. Not because it is some conspiracy by Big Pharma, but because it is the greatest advance, in our field, since my inclusion in 1980.
    Can we just agree that EVERY patient has a right to be thoroughly educated on the benefits and liabilities of ALL models of recovery and allowed to pursue the model, that they feel best meets their needs. I know that you believe this concept in theory, however, your bias against MAT consistently seeps into your columns.
    Regardless, I enjoy your efforts to bring about dialogue, however, there are just too many people dying to not advocate for the model that has the greatest opportunity to stop the deaths.

    • Interesting that evidence is presented (simply by digging down into the papers) which contradicts the conclusions the authors claim in their meta-analysis, but this is then turned into an accusation of bias. If there is bias, it is surely in favour of Opiate Replacement Therapy. When you claim ‘France’s tremendous results’ what are your outcome measures? Do they match what patients want from treatment? Abstinence rates from residential rehab vary, but in programmes which give a decent dose of treatment for long enough, the outcomes are much better than 5% for sustained abstinence. I’d be interested to see your references for your low rates because that’s not what treatment outcome studies tell us.

      I think we can all agree that patients need to be informed and make informed choices. This simply doesn’t happen consistently and it’s important to highlight the flaws in published evidence to help patients make those choices. This series has demonstrated that clearly and if you have an issue with the evidence you ought to take the argument there instead of ad hominem arguments of bias.