Recovery from opioid addiction is also more than remission, with remission defined as the sustained cessation or deceleration of opioid and other drug use/problems to a subclinical level—no longer meeting diagnostic criteria for opioid dependence or another substance use disorder. Remission is about the subtraction of pathology; recovery is ultimately about the achievement of global (physical, emotional, relational, spiritual) health, social functioning, and quality of life in the community.
I have frequently posted about the importance of research looking at the quality of life of treatment patients.
When you hear or read someone say something like, “this treatment approach is the most evidence-based,” we should follow-up with the question, “evidence-based for what outcome?”
Statements like this are frequently made about MAT and follow-up questions are rarely asked and answered.
Unfortunately, the evidence-base says very little about the quality of life of the research subjects. Most studies focus on measures like reduced days of illicit drug use, reduced criminal activity, reduced disease transmission, and reduced overdose rates. Of course, these are important outcomes, but they fall far short of the outcomes desired by most patients and families.
A recently published study looks at what they call “functional outcomes.” These include “cognitive (e.g., memory), physical (e.g., fatigue), occupational (e.g., return to work), social/behavioral (e.g., criminal activity), and neurological (e.g., balance) function.”
These are moving in the direction of quality of life measures. Good!
They did not conduct a study with patients, instead they reviewed existing research to see what can be learned.
So . . . how much research had anything to say about these kinds of measures?
A comprehensive search followed by 1411 full text publication screenings yielded 30 randomized controlled trials (RCTs) and 10 observational studies meeting inclusion criteria.
Only 40? That’s disappointing, but how useful were those 40?
Functional measures were primary outcomes in only six RCTs; it is unclear if the other trials, which were powered statistically to detect differences in illicit drug use or treatment retention, had adequate power to detect differences in functional effects.
They summarized findings addressing the following areas:
- cognitive speed
- family functioning
- psychological function
- criminal activity
- arrests and incarceration
- legal status
The researchers summarized their findings this way:
Several of the individual studies that compared OUD patients who received MAT to those who did not reported significant positive effects of MAT on functional outcomes. However, in several studies, MAT patients performed significantly worse than matched healthy controls. Because of the limited number and quality of the studies, the quality of evidence supporting significant differences is low or very low. The only exception is moderate quality evidence supporting a lower prevalence of fatigue with buprenorphine compared to methadone.
There are legitimate questions to be raised about the comparisons. For example, are healthy controls the right comparison group? Is placebo the right comparison group. We might also ask if the researchers’ standards for inclusion were too high.
Whatever opinions one holds on those questions, it seems pretty clear that there is a disconnect between the way the evidence is frequently discussed and what we can actually conclude from it.
This doesn’t mean MAT is bad or should not be available. It simply means the research doesn’t speak to outcomes most patients are seeking. We should acknowledge this when we discuss the evidence and researchers should seek answers to quality of life questions.
Here’s what I’ve said repeatedly in this blog:
People with addiction should be told about the treatments that exist, and the evidence for them. When discussing the evidence for an approach, they ought to be informed about the extent to which the evidence aligns with their goals.
Then, they should be told about the treatments that are available to them. And, they ought to be told why some treatments aren’t available to them—not covered, too expensive, no provider available, policy barriers, etc.
Then, they should be free to choose the treatment they prefer. And, within reason, they should be free to change their mind.