“bad doctors are not going to become good doctors because you give them more rules”

I’ve posted before about maintenance medications, like buprenorphine, that are frequently referred to as the gold standard.

I’ve also posted about how there may be a discrepancy between the kinds of outcomes people with opioid addiction are seeking and the outcomes found in the evidence-base for maintenance treatments.

I’ve also pointed out that, while many institutional advocates for maintenance treatments claim that maintenance medications are “highly effective when combined with other behavioral supports,” their own evidence cast doubt on their advocacy.

Ohio has had serious problems with ethically dubious buprenorphine prescribers.

One policy response to these kinds of practices is to require that buprenorphine patients receive counseling. It is consistent with the institutional advocacy mentioned above and constitutes a standard of care that is thought to be incongruent with the practices of a “pill mill.”

Apparently, Ohio already requires counseling for buprenorphine patients and their medical board is considering rule changes to be more prescriptive about the counseling required.

Unfortunately, the article doesn’t say much about the proposed changes. The only relevant proposed changes are these, so I’m assuming they are the proposed rules.

The state business impact analysis offers the following rationale:

The need for regulation is urgent, as there are reports that some prescribers are setting up “pill mills” for specifically approved buprenorphine products, similar to the “pill mills” where prescription opiates such as OxyContin and Vicodin were prescribed for other than legitimate medical purposes (see http://www.nytimes.com/2013/11/17/health/in-demand-in-clinics-and-on-the-street-bupe-can-be-savior-or-menace.html?_r=1&). Recognizing the constellation of factors related to opiate addiction, treatment, and illegal activity, the rules attempt to strike a proper balance between access to opiate addiction treatment and diversion of specifically approved buprenorphine products by setting forth the requirements for treating opiate addiction in a non-institutional setting so that the treatment can be performed in a safe manner for the patient and reduce the risk of unlawful behavior of patients, practitioners, and others.

However, the counseling requirement is getting pushback:

Several doctors have raised issues with the requirement to get counseling, saying it isn’t medically necessary and limits the number of doctors offering MAT and number of patients getting help.

. . .

The Ohio Society of Addiction Medicine has objected to the counseling requirement, citing a 2018 Substance Abuse and Mental Health Services Administration document called Treatment Improvement Protocol 63.

“Four randomized trials found no extra benefit to adding adjunctive counseling to well-conducted medical management visits delivered by the buprenorphine prescriber,” it says.

Gregory Boehm, the Ohio society’s president, wrote the group agrees. “Counseling does not improve outcomes,” he said.

The article addresses some of the issues identified in the rulemaking rationale:

. . . some doctors . . .  in Dayton who are operating cash-only clinics, giving out Suboxone with no other services or referrals to further treatment. For about $200 a client can get a 90-day prescription, which he said they can turn around and sell on the street for $2,000.

And while they paid cash to the doctor for the visit, they may have used Medicaid to fill the prescription, meaning tax money is funding street drug trade . . .

“I understand the State Medical Board of Ohio’s desire to put these doctors out of business,” she said. “The issue is bad doctors are not going to become good doctors because you give them more rules.”

Gold Standard?

All of this should invite questions about why this approach is so frequently referred to as the gold standard.

Bill White, who is an advocate for maintenance treatment, wrote the following in 2010:

As a professional field, we know a great deal about what methadone maintenance treatment can eliminate from the lives of patients, but we know very little from the standpoint of science about what it adds. In fact, we know very little about the stages and styles of long-term medication-assisted recovery.

In the midst of this, we have the FDA and federal agencies lowering the bar by promoting what they refer to as “alternative endpoints” that would make reduced drug use an acceptable endpoint for drug trials.

And, we’ve heard an oft repeated mantra of “maintenance medications reduce overdose deaths by half” for several years. Yet, I’ve pointed out that it doesn’t appear to be that simple–communities and countries that have emphasized harm reduction and maintenance treatments do not seem to be getting spared.

Now, this doesn’t mean that methadone doesn’t reduce death rates. It means that the death rate is still very high.

One observation that might help makes sense of this is the following:

This fact cannot be underscored enough. Most evidence showing 50% or more mortality reduction using Bupe or methadone is old data – pre-fentanyl, often relying on Europe (France) as model to emulate. https://t.co/6eq2JLT31a

— Dr. Rick Barnett (@drrickbarnett) April 5, 2019

This seems plausible, but I haven’t seen the data. (I’ve requested a source and will share it here, if provided.)

It’s worth mentioning that there is a highly effective treatment model that doesn’t have to be too expensive and might be adapted to other populations. Unfortunately, it does not fit the popular narratives and does not get any attention from the press.

I’ll also throw in a reminder from a previous post about were I stand on maintenance treatments:

Just to be sure that my position is understood. I’m not advocating the abolition of maintenance treatments.

Here’s something I wrote in a previous post: “All I want is a day when addicts are offered recovery oriented treatment of an adequate duration and intensity. I have no problem with drug-assisted treatment being offered. Give the client accurate information and let them choose.”

Another: “Once again, I’d welcome a day when addicts are offered recovery oriented treatment of an adequate duration and intensity and have the opportunity to choose for themselves.”

It’s also worth noting that there is a link between AA and methadone.