It takes a treatment that works.

I usually bristle at attempts to correct and manage other people’s well-meaning speech. However, this headline from the Washington Post grabbed me.

It doesn’t take a warrior to beat cancer. It takes a treatment that works.

How true this is for addiction, too.

There is a treatment that delivers long term abstinence rates north of 70%. (One study of 904 patients found 5 year abstinence rates of 79% with only 4% experiencing 2 or more relapses.) Research also indicates that it is just as effective with patients who are injection drug users.

What’s sad is that very few people get access to this model.

To make matters worse, this model is rarely discussed. Advocates focus their efforts on approaches associated with reduced drug use and symptoms rather than long term abstinence and, often, are silent on this gold standard approach.

The treatment industry is full of hustlers. How do we know this isn’t just another hustle? There are at least 2 reasons to believe in it.

  1. It’s been studied and published.
  2. This approach is used on addicted physicians and pilots. (If you want to know the best treatment option for a health problem, find out which approach doctors choose for themselves, their peers, and loved ones.)

They get a certain combination of treatment, monitoring, and support. And, importantly, they get the right dose, duration, and quality.

Why do we hear so little about this?

It does demand a lot of the patient. It demands a lot of health care providers.

This being the case, it should not be the only option.

But, every patient ought to know about it and it should be an option for all.

Here’s a previous post that provides more information on common objections.

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Discrimination1

I frequently point to health professional recovery programs when discussing the effectiveness of drug-free treatment when it’s delivered in the appropriate dose, frequency and duration. They have stellar outcomes. (More details here.)

The programs were abstinence-based, requiring physicians to abstain from any use of alcohol or other drugs of abuse as assessed by frequent random tests typically lasting for 5 years. Tests rapidly identified any return to substance use, leading to swift and significant consequences. Remarkably, 78% of participants had no positive test for either alcohol or drugs over the 5-year period of intensive monitoring. … The unique PHP care management included close linkages to the 12-step programs of Alcoholics Anonymous and Narcotics Anonymous and the use of residential and outpatient treatment programs that were selected for their excellence.

I generally get three counter-arguments:

  1. That health professionals have more recovery capital and are more likely to recover than other addicts.
  2. That the threat of license suspension/revocation provides a unique combination of carrot and stick. We’ll never get that kind of engagement with regular people.
  3. That treating everyone in this manner would be too expensive—we’ve made a decision, as a culture, that we’re willing to invest this time and capital into addicted doctors but we can’t do it for everyone.

I want to respond to these arguments in this post.

1. “Health professionals have more recovery capital and are more likely to recover than other addicts.”

There may be ways in which health professionals are unique in terms of recovery capital. This may be true. However, they also face a unique set of barriers when initiating recovery. A study of physician recovery programs (this excludes health professionals other than physicians) found high rates of opioid addiction (35%), high rates of combined alcohol and drug problems (31%) and high rates of psychiatric problems (48%). In addition, 74% were not self-referred.

Further, health professionals confront easy access to drugs and with this ease of access to prescription drugs, they often develop tolerance levels that dwarf those of street addicts.

Two pieces of folk wisdom may also be relevant:

  • “Doctors make the worst patients.”
  • “I’ve never met anyone too dumb for recovery, but I’ve met plenty of people who were too smart.”

So…they may have unique advantages, but they also have unique barriers. If there is a difference, is there reason to believe it’s stark enough to it wouldn’t work for other addicts?

2. “Heath professionals are uniquely motivated because of the threat of license suspension/revocation.”

This is probably the strongest counter-argument.

Health professionals place incredibly high value on their profession. They often put enormous time, effort and money into becoming a health professional, but it’s more than that. Their profession often becomes integral to their identity and is a key source of meaning and purpose. In health professional recovery programs, we’ve constructed a system that uses this incredibly powerful element of the addict’s life to initiate and maintain their recovery. And, it’s not just threats. They offer a path to returning to work in a pretty expeditious time-frame, they provide peer support, they develop contracts with employers that provide both support and monitoring.

What would happen if we constructed systems that identified and used (not through coercion or manipulation) elements of the addict’s life that are integral to their identity and are a key sources of meaning and purpose? Debra Jay has developed one model of recovery support that seeks to do exactly this. (Interestingly, she’s had to develop a model that doesn’t require professionally directed services, because it’s not covered by insurance and many families may not be able to afford it.)

What else could be done? We don’t know. Because, as a system, we haven’t tried.

I recently blogged on the issue of coercion and health professional recovery programs and said this:

. . . it is our experience that attracting people to the front door is pretty easy if you have an attractive back door. In our case, this includes:

  • safe, affordable and stable sober housing;
  • opportunities for stable employment with advancement opportunities;
  • a large, welcoming and energetic recovering community (with lots of opioid addicts in long term recovery);
  • two local collegiate recovery programs that support a path to college degrees; and
  • lots of recovery role models providing support and demonstrating that all of this is do-able.

If we can create systems that provide this kind of back door and integrate long term recovery monitoring and support, I think it could go a very long way toward overcoming the long-term-voluntary-engagement-without-coercion issue.

. . .

I’m not suggesting that we’ll have relapse rates as low as 22% over 5 years. I’m also not suggesting that it’d be easy to keep people engaged for 5 years. But, what’s possible? Huge improvements, I’d imagine. But, we don’t know, because we haven’t tried.

Imagine that we tried and engaged in continuous improvement for 10 years. How far could we go?

3. “Treating everyone in this manner would be too expensive.”

So, then, what is provided and what might it cost to replicate it?

First, what is provided:

The first phase of formal addiction treatment for two thirds of these physicians (69%) was residential care often for 90 days. The remaining 31% began treatment in an intensive day treatment setting. The participants at this stage usually received multiple intensive sessions of group, individual, and family counseling as well as an introduction to an abstinence-oriented lifestyle through required attendance at Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Caduceus meetings (a collegial support association for recovering health professionals) and other mutual-aide community groups. Frequent status reports on treatment progress were required by most PHPs.

Use of pharmacotherapy as a component of treatment for SUDs was rare. Very few of the treatment programs or the medical directors of the PHPs used any of the available maintenance or antagonist medications.

After completion of initial formal addiction treatment, all PHPs developed a continuing care contract with the identified physician consisting of support, counseling, and monitoring for usually 5 years. Most PHPs (95%) also required frequent participation in AA, NA, or other self-help groups and verification of attendance at personal counseling and/or Caduceus meetings.

Physicians were tested randomly throughout the course of their PHP care, typically being subject to testing 5 of 7 days a week.

Physicians were typically tested an average of four times per month in the first year of their contracts for a total of about 48 tests in the year. By the fifth year, the average frequency of testing was about 20 tests per year.

How much would this cost to replicate? The following is based on Dawn Farm’s fees and costs.

  • $16,800 – 120 days of residential treatment plus unlimited aftercare groups
  • $5460 – 364 drug screens over 5 years ($15 per screen. 2x per week for first 2 years, 1x per week for years 3-5.)
  • $10,000 – 100 outpatient group sessions ($25) and 100 outpatient individual sessions ($75)
  • $5000 – 5 years of recovery support and monitoring from a Recovery Support Specialist with a caseload of 40 (A former head of Michigan’s monitoring program reports that their Case Managers have approximately 150 cases each.)
  • Total = $37,260

Now, this does not include one important element—a workplace monitor and a career employer making contract compliance a condition of employment. However, we offer transitional housing to clients for up to two years.

At less than $38,000 for the whole package, in the context of American healthcare spending, this does not seem to be an unsustainable burden and, in fact, is likely to be a very wise investment in pure financial terms. It’s in the same ballpark as inserting a stent–just the procedure, excluding continuing care, medications, etc. We implant 2,000,000 stents per year.

Imagine what would be possible if 2,000,000 addicts were given that opportunity. Imagine what we could learn.

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Another buprenorphine retention finding

Source: Abby Covert

There has been a lot of discussion about the use of buprenorphine to treat addiction and prevent overdose.

I’ve pointed out that weak retention rates weaken this rationale.

One common response is that the treatment system and recovering community reinforce stigma associated with maintenance medications and undermine outcomes, including retention.

This makes retention findings from other countries and cultures of interest.

The Journal of Substance Abuse Treatment just published a report on a small study of buprenorphine maintenance retention in young adults in India.

First, a natural question is, “What does treatment look like in India?”

The current study was conducted at an apex (tertiary level) substance use disorder treatment centre from the northern part of India. It is a WHO Collaborating Centre on Substance Abuse. The facility is a 50 bedded centre which is involved in providing clinical services, capacity building, conducting research, and guiding policy decisions for addiction related issues in India. The centre offers both inpatient and outpatient treatment, along with services for psychotherapeutic interventions and psycho-social rehabilitation.

Patients are primarily admitted at the centre for opioid and alcohol detoxification. The duration of admission is typically for 2–3 weeks. During the inpatient stay, patients are provided medications for symptomatic management of withdrawal symptoms. Medications for detoxification at the centre typically include benzodiazepines for alcohol use disorders and buprenorphine for opioid use disorders. After detoxification, the patients are started on medications for long term phase. Treatment for co-occurring psychiatric disorders is also provided (Sarkar, Balhara, Gautam, & Singh, 2016).

The centre offers maintenance therapy for opioid use disorders in form of buprenorphine (including buprenorphine-naloxone combination) (Balhara & Jain, 2012; Prakash & Balhara, 2016). Buprenophine induction can occur in the out-patient as well as in-patient setting. After initial period of dose stabilization buprenorphine is dispensed on a daily basis for a period of three months. Subsequently, the patient is shifted to take home doses of buprenorphine-naloxone combination that is dispensed on a biweekly basis, before shifting the patients to a weekly dispensing regimen. The earlier practice of alternate day dispensing (dose for two days administered on one day and the patient shall visit on alternate day) has been discontinued at the centre before the data collection period for the current study (Balhara, 2014). The patients are also provided counseling and rehabilitation services. These interventions are more intensive in the in-patient setting as compared to the out-patient setting.

What did they find?

The current study found the retention rates on buprenorphine maintenance to be 33.8% at 90 days, 19.11% at 6 months and 11.8% at 12 months.

See other posts about buprenorphine findings here.

As I’ve said many times, none of this is to suggest that buprenorphine should not be available to any patient who chooses it. It’s just a push for good informed consent that empowers patients to advocate and choose for themselves.

This information is too often elided, even when delivering legitimate criticisms of other treatment approaches.

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Toward a “Conspiracy of Hope” (Bill White and Jason Schwartz)

This is being cross-posted from williamwhitepapers.com. Please visit and subscribe. (You won’t regret it!)


conspiracy-of-hopeSo it is not our job to pass judgment on who will and will not recover from mental illness and the spirit breaking effects of poverty, stigma, dehumanization, degradation and learned helplessness. Rather, our job is to participate in a conspiracy of hope. It is our job to form a community of hope which surrounds people with psychiatric disabilities. —Pat Deegan

With those words, Dr. Patricia Deegan, Adjunct Professor at Dartmouth College Geisel School of Medicine and indomitable recovery advocate, introduced two ideas with potentially profound implications for the future of addiction treatment and recovery. Below we offer a few reflections on these ideas.

A conspiracy of hope is an organized movement to inject the optimism of lived recovery experience into an arena historically fixated on addiction-related pathology and its progeny of injuries to individuals, families, and communities. But why is there need for such a conspiracy? Opposition to prevailing conditions often arises within the context of oppression. People suffering from addiction and those seeking recovery face innumerable sources of such oppression.

Addiction itself inflicts a rising cascade of consequences, crushing one’s sense of value and blinding one’s vision beyond the insatiable immediacy of drug hunger. Addiction-related social stigma—fueled by media fixation on the most lurid caricatures of addiction—further damages personal identity, fuels social isolation or entrenchment in subterranean drug cultures, and prevents or slows help-seeking. The resulting addiction-based social network behaves like crabs in a bucket—those trying to escape are repeatedly pulled back in. The paucity of helping resources and their lack of accessibility, affordability, and quality all reinforce the view that reaching out for help would be a waste of time and money. When help is sought, the therapeutic pessimism and paternalism of professional and nonprofessional “helpers” can also reinforce low recovery expectations.

As a result of such conditions, addiction-fueled despair whispers and then shouts that we are not deserving or capable of anything different—that recovery is a myth and that the ever-present threats of incarceration, disability, or death are rightful consequences of our unworthiness. Only an organized conspiracy of hope can challenge the oppressive conditions that stand as major barriers to long-term addiction recovery.

Character of the Conspiracy

But what would such a conspiracy of hope require? It would require the cultural and political mobilization of individuals and families in recovery and their allies. It would require a vanguard of such individuals and families willing to share their recovery stories at a public level. It would require those in recovery to move beyond their own personal stories and their particular recovery pathway to identify themselves as “a people” with a shared history, shared needs, and a shared destiny. In short, it would require a social movement aimed at shifting the governing image of addiction from that of the repeatedly relapsing celebrity to the millions of people living quiet lives of stable, long-term recovery. Shifting the dominant view of addiction from one of pessimism to hope will require the involvement of a broad spectrum of people and professions, but people in recovery will be central to this achievement through their individual and collective storytelling and their leadership within recovery advocacy efforts.

There are whole professions whose members share an extremely pessimistic view of recovery because they repeatedly see only those who fail to recover. The success stories are not visible in their daily professional lives. We need to re-introduce ourselves to the police who arrested us, the attorneys who prosecuted and defended us, the judges who sentenced us, the probation officers who monitored us, the physicians and nurses who cared for us, the teachers and social workers who cared for the problems of our children, the job supervisors who threatened to fire us. We need to find a way to express our gratitude at their efforts to help us, no matter how ill-timed, ill-informed, and inept such interventions may have been. We need to find a way to tell all of them that today we are sane and sober and that we have taken responsibility for our own lives. We need to tell them to be hopeful, that RECOVERY LIVES! Americans see the devastating consequences of addiction every day; it is time they witnessed close up the regenerative power of recovery. (White, A Day is Coming, 2001)

What makes this a conspiracy is the knowledge that through these simple acts of storytelling and advocacy we are part of a chorus of others taking similar strategic steps to achieve larger social gains. Built on the back of earlier recovery advocacy efforts, this conspiracy of hope was officially launched at the 2001 Recovery Summit in St. Paul, Minnesota. Christened the New Recovery Advocacy Movement, it has since spread throughout the U.S. and internationally. But the success of this movement hinges on more than our collective storytelling; in Deegan’s vision, it requires a new form of community-building.

Building Communities of Hope

Communities of hope involve creating the physical, psychological, and social space (recovery landscapes) in local communities and the culture at large in which recovery from addiction can flourish. Assuring such space requires building sustainable institutions through which recovery is supported within every area of community life, e.g., government, business and industry, housing, education, medicine, social services, religion, music, the arts, sports, and leisure. The idea of communities of hope means that people in recovery have opportunities to be supported by and in turn support other people in recovery and that those in recovery have opportunities individually and collectively to participate in the larger life of their communities. It also suggests the presence of safe sanctuaries that can serve as incubation chambers for those early in their recovery. We are now witnessing the spread of such new institutions (e.g., recovery community centers, recovery homes, recovery industries, high school and collegiate recovery programs, recovery cafes, recovery ministries, recovery-focused sports and entertainment venues, and recovery celebration events) that transcend the historical categories of addiction treatment or recovery mutual aid societies.

We are also witnessing the emergence of an ecumenical culture of recovery with language that links the distinctive cultures that have historically evolved within these professional and mutual aid settings. Within the addictions arena, the communities of hope that Deegan refers to are under construction across the U.S. and in other countries. That stands as a notable historical milestone within the history of addiction recovery. It is a trend that will benefit individuals seeking recovery and the service systems designed to serve them, but it will also mark a step in elevating the broader health and quality of communal life. We have followed closely the work of John McKnight, Peter Block, and Bruce Alexander on the value of deliberate welcoming, sharing gifts, and collaborative community building and commend their writings to recovery advocates and addiction professionals.

Implications for Addiction Treatment Programs

What does all this mean for addiction treatment programs? Addiction treatment programs could participate in this conspiracy of hope and recovery community building by taking actions such as the following:

*Elevating resilience and recovery as the central organizing constructs for the design and delivery of all services, e.g., strengths-based assessment protocol, recovery-focused training of all service personnel on the prevalence, processes, pathways, stages, and styles of long-term personal and family recovery. Identification and mobilization of client gifts are essential. Conspiracies of hope and communities of hope are built upon participant’s gifts, not their needs.

* Reconnecting what have become ever-briefer episodes of addiction treatment to the larger and more enduring process of addiction recovery via embracing  models of recovery management nested within larger recovery-oriented systems of care, e.g., precovery outreach services, assertive linkage to indigenous recovery support institutions, sustained post-treatment recovery checkups, and support services for families in long-term recovery.

*Assuring the presence, diversity, and visibility of people in long-term recovery within the treatment milieu.

* Actively supporting (without controlling or exploiting) local recovery advocacy and recovery community building activities.

* Using community standing to expand the conspiracy beyond people in recovery and beyond service providers, e.g., engaging employers and faith communities as well as other social institutions to make the community “recovery ready.”

Joining the Conspiracy

The journey from addiction to recovery is as possible and fulfilling as it is challenging. Few things are as spiritually energizing as being part of a “conspiracy of hope” to support those journeys. Such journeys are eased when nested within a community of fellow travelers. Few things are as fulfilling as being part of building such communities. Are you ready to join the conspiracy of hope and nurture the development of communities of hope? What steps could you take today to assert such a commitment?

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Blue Cross Blue Shield Publishes Major Opioid Report

Blue Cross Blue Shield issued a report on the opioid crisis with their data from all members in their commercial plans.

Early in the document, they report a pair of striking numbers.

First, that 21% of members filled a prescription for an opioid in 2015. I’ve heard these kinds of numbers before, but I never get numb. That’s 1 in 5 members, despite growing attention to excessive prescribing of opioids.

Second, a 493% increase in diagnosis of opioid use disorders over 7 years. My reaction is that this has to reflect changes in coding or diagnostic practices rather than the population. It’s implausible that there was an increase this large in the number of people with an opioid use disorder.

The document then devotes a great deal of attention to opioid prescribing.

Toward the end, there are a couple of graphics that caught my attention.

First, a map showing rates of opioid use disorders.

Then, this:

Though critical to treating opioid use disorder, the use of medication-assisted treatments (e.g., methadone) does not always track with rates of opioid use disorder (compare Exhibits 10 and 11). For example, New England leads the nation in use of medication-assisted treatments but it has lower levels of opioid use disorder than other parts of the country

So . . . they note that New England has average rates of opioid use disorders, yet they have high rates of utilization of medication-assisted treatment.

This caught my attention because New England has higher rates of overdose, as depicted in the CDC graphics below.

Number and age-adjusted rates of drug overdose deaths by state, US 2015

Statistically significant drug overdose death rate increase from 2014 to 2015, US states

(It’s worth noting that BCBS is not among the top 3 insurers in Maine or New Hampshire, but they are the biggest in Massachusetts and Vermont.)

It begs questions about what the story is, doesn’t it?

I don’t presume to know the answers.

  • What was the sequence of events for the high OD rates and the utilization of MAT? And, what impact, if any, has the expansion of MAT had on overdose rates?
  • Is the BCBS data representative? (This brand new SAMHSA report suggest that the data about use is representative.)
  • We know that opioid maintenance meds reduce risk of OD, but we also know that people stop taking these meds at high rates. Does this imply that, in the real world, these meds end up providing less OD protection than hoped?
  • What are the policies and practices of the other insurers in the state?  (For example, we know that Anthem [the largest insurer in Maine and Vermont] recently ended prior authorization requirements for MAT. It’s not clear how restrictive they had been. They also are attempting to institute reforms to address the fact that, “only about 16 to 19 percent of the members taking the medications for opioid use disorder also were getting the recommended in-person counseling.”)
  • Are there regional differences in drug potency that explain this?

Let’s hope that more insurers follow suit and share their data.

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Getting the cannabis tax right

National Affairs recently published an article on the complexity and importance or taxing marijuana correctly:

While marijuana has tens of millions of happy occasional users, they account for a trivial share of industry sales. Consumption is concentrated among the smaller number of high-frequency users; half of marijuana is consumed by people with a medically diagnosable substance-use disorder, and these individuals are disproportionately poor and less educated. Policy — including tax policy — should be designed to protect these problem users from exploitation by industry and from their own bad choices, rather than cater to the convenience of occasional users.

Lower prices for marijuana have been shown to increase use, particularly for younger and heavier marijuana users. Hence, a major goal should be to keep after-tax prices from falling too sharply (ideally by no more than 50%). Dictating that outcome only via minimum-pricing rules, however, would let industry pocket excess profits. Propping up prices with excise taxes — a favored strategy for tobacco — would achieve the public-health goal of discouraging excessive marijuana use, while relieving the public of having to finance government via other less-popular and more-counterproductive taxes.

Alas, taxing marijuana is not simple. Federal legalization — specifically, allowing for-profit corporations to sell marijuana — would unleash a dynamic market that would evolve precipitously and unpredictably, with the potential for aggressive anti-tax lobbying, price collapses, rapidly changing marijuana-derived products, and black- and gray-market tax evasion. All this would create complicated secondary goals: Taxes would need to be nearly uniform across states; they would need to cover a wide variety of products; and they would need to increase dramatically over time.

Here’s just one example of the complexity discussed:

A first impulse might be to say, “If you want prices to be $6 per gram when the cost is $1 per gram, just make the tax $5 per gram.” Alas, it’s not that simple. Weight-based taxes create incentives to sell high-potency forms of marijuana. Potency is already up: Flowers sold in Washington state’s legal market now average over 20% THC, whereas the average potency of cannabis (at least the cannabis discovered and confiscated by law enforcement) did not rise above 5% until 2001.

Take the time to read the entire article here.

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Opioid users complete residential at higher rates than other patients

Residential treatment has received a lot of criticism and skepticism over the last several years, especially for opioid use disorders. (Some of it is deserved. Too many providers are hustlers and others provide little more than detox with inadequate follow-up. Of course, many of the same criticisms have been directed at medication-assisted treatment. But, that’s not what this post is about.)

At any rate, the Recovery Research Institute recently posted about a study looking at completion rates for outpatient and residential treatment.

The study looked at A LOT of treatment admissions, 318,924.

Residential completion rates appear to have surprised a lot of people:

Results: Residential programs reported a 65% completion rate compared to 52% for outpatient settings. After controlling for other confounding factors, clients in residential treatment were nearly three times as likely as clients in outpatient treatment to complete treatment.

But, what really surprised some readers was this:

Opioid users were much more likely to benefit from residential treatment compared to alcohol users. . . .

We speculate that for opioid abusers, the increased structure and cloistering of residential treatment provide some protection from the environmental and social triggers for relapse or that otherwise lead to the termination of treatment that outpatient treatment settings do not afford. Indeed, environmental risk characteristics in drug abusers’ residential neighborhoods, such as the presence of liquor stores and indicators of concentrated disadvantage at the neighborhood level, have been found to be associated with treatment non-continuity and relapse. Such environmental triggers may play a particularly substantial role for those addicted to opioids compared to those seeking treatment for marijuana abuse. Since opioid users have the lowest raw completion rates in general, this finding that residential treatment makes a greater positive difference for opioid users than it does for any of the other substances represents an important result that merits further investigation. Given the current epidemic of opioid-related overdoses in the U.S., our results suggest that greater use of residential treatment should be explored for opioid users in particular.

For the differences between residential and outpatient, they say the following:

In general, residential treatment completion rates are usually higher compared to outpatient settings, but what is particularly noteworthy is that even after controlling for various client characteristics and state level variations, the likelihood of treatment completion for residential programs was still nearly three times as great as for outpatient settings. Given the more highly structured nature and intensity of services of residential programs compared to outpatient treatment, it is understandable that residential treatment completion rates would be higher. It requires far less effort to end treatment prematurely in outpatient settings com-pared to residential treatment. Given the strong association between treatment completion and positive post-treatment outcomes such as long term abstinence, the large magnitude of difference between outpatient and residential treatment represents a potentially important consideration for the choice of treatment setting for clients.

This is no surprise to us and it’s consistent with our experience over the life of our program.

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Buprenorphine: Being out of treatment increases risk of death nearly 30-fold

Choose you evidence carefully by rocket ship

The title of this post is taken directly from a press release for a recently published study. Here’s the summary:

Buprenorphine reduces mortality for those with opioid use disorder, but periods off treatment are associated with much higher mortality rates. A study of 713 new outpatient users of buprenorphine was conducted in France, where patients with opioid use disorder are usually treated by general practitioners in private practice with periods in and out of treatment. The mortality rate for study subjects was 0.63/100 person-year [95 percent CI 0.40- 0.85], compared to 0.24/100 person-year [0.24-0.25] for other individuals of the same age range during the same time period. The authors encourage physicians to avoid interruption of treatment and encourage patients to remain in treatment for a sufficient amount of time.

There’s no debate that buprenorphine provides protection against overdose when patients are taking it.

However, that’s a very important qualifier and it often gets lost when talking about the evidence for treatment options.

The problem is that studies have not been very successful at getting people to take it on an ongoing basis.

In a study published earlier this year, they looked at records of 38,000 american buprenorphine patients. What did they find?

For their study, Alexander and his colleagues examined pharmacy claims for more than 38,000 new buprenorphine users who filled prescriptions between 2006 and 2013 in 11 states. They looked at non-buprenorphine opioid prescriptions before, during, and after each patient’s first course of buprenorphine treatment, which typically lasted between one to six months. Even though there are no universally agreed-upon guidelines regarding the optimal length of treatment, most people discontinued buprenorphine within three months.

They found that 43 percent of patients who received buprenorphine filled an opioid prescription during treatment and 67 percent filled an opioid prescription during the 12 months following buprenorphine treatment. Most patients continued to receive similar amounts of opioids before and after buprenorphine treatment.

They described buprenorphine’s impact and retention like this:

Buprenorphine therapy was associated with modest declines in most measures of opioid use following the first treatment episode; however, only 33% of patients continued to fill prescriptions for buprenorphine after 3 months.

So . . . protection from overdose is one of the most important benefits of buprenorphine treatment, BUT by day ninety, 67% of buprenorphine patients are no longer taking the drug and therefore not protected from overdose.

PS – This is not meant to imply that buprenorphine is bad, or shouldn’t be an option. One of the limitations of abstinence-based treatments is that they also struggle with retention and the risk of overdose when relapse occurs.

PSS – (For a more comprehensive review of a frequently cited meta-analysis of medication-assisted treatment, check this out.)

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