no hint of opinion here

SecondOpinion400

To me, the most important line in the NY Times Suboxone series was this one, “[Dr. Sullivan] considered opioid addiction “a hopeless disease'”.

We believe that maintenance approaches are rooted in the belief that most opiate addicts are not capable of recovering in the same manner that doctors recover.

Most of the arguments for maintenance treatments focus on reduced harm and its relative risks, very few focus on quality of life or achieving full recovery.

It’s also worth remembering that Suboxone compliance rates aren’t what they used to be.

The post below was originally published on 6/26/13. I decided to repost it to accompany the posts from the last few days.

*   *   *

From an article about a new report on medications for opiate treatment:

The report also examined studies that evaluated buprenorphine, methadone, injectable naltrexone, and oral naltrexone and concluded a benefit in patient outcomes as well as costs.

“I can say with no hint of opinion here, it’s simple fact, they are all effective,” McLellan said. “They’re effective not just in reducing opioid use, they’re effective in so many other ways that are important to societies and families.”

Effective. It’s a fact. No opinion here. Hmmm.

Effective at what? These drugs are effective at reducing opiate use. If that outcome is all one wants, they may be a good option.

The problem is that it’s a palliative response, when we know that full recovery is possible if the right resources are made available. (Of course these treatment approaches are not the ones physicians choose for themselves and their peers.)

Let’s see what the report says about another outcome that might speak more directly to quality of life, say, employment [emphasis mine]:

These studies have also measured various types of related outcomes such as reductions non-opioid drug use, employment and criminal activity. Here the literature is quite mixed and appears to be a result of the particular patient population, the clinical approach of the methadone maintenance program and the available counseling and social services provided.

and

As with methadone, the literature is quite mixed with regard to reducing non-opioid drug use, improving employment and reducing crime.

and

He also found improvements within the methadone maintenance group across various time periods on HIV risk behaviors, employment and criminal justice involvement. [My note: In this study, employment increased from approximately 21% to approximately 31%.]

So…while there’s little doubt that these medications reduce opiate use and overdose deaths, the quality of life evidence is considerably weaker.

With the increases in opiate ODs, I understand families and individuals struggling with these decisions. I struggle to come up with the best analogy for informed consent. Maybe something like this?

Maybe the choice is something like a person having incapacitating (socially, emotionally, occupationally, spiritually, etc.) and life-threatening but treatable cardiac disease. There are 2 treatments:

  1. A pill that will reduce death and symptoms, but will have marginal impact on QoL (quality of life). Relatively little is known about long term (years) compliance rates for this option, but we do know that discontinuation of the medication leads to “near universal relapse“, so getting off it is extremely difficult. The drug has some cognitive side-effects and may also have some emotional side effects. It is known to reduce risk of death, but not eliminate it.
  2. Diet and exercise can arrest all symptoms, prevent death and provide full recovery, returning the patient to a normal QoL. This is the option we use for medical professionals and they have great outcomes. Long-term compliance is the challenge and failure to comply is likely to result in relapse and may lead to death. However, we have lots of strategies and social support for making and maintaining these changes.

The catch is that you can’t do both because option 1 appears to interfere with the benefits of option 2.

Non-Violent State Inmates Declining for 20 Years

From Keith Humphreys:

Prison is the subject of many myths in the public policy world. For example, many people believe that the size of the prison population has continued to rise under President Obama, when in fact it has fallen. Other observers maintain that prison populations drop during economic downturns, when in fact the reverse has generally been true. An even more widely embraced myth is that states have been increasingly incarcerating non-violent offenders. But as this chart from the Bureau of Justice Statistics (BJS) shows, the proportion of the state prison population that is serving time for a non-violent crime has been declining since the early 1990s.

I want to read more about this. I know that prison populations have been declining in recent years, but my impression was that they’ve grown considerably over 20 years and that violent crime is down. Those impressions may have been wrong, but if they are not, I want to see how you have shrinking violent crime, growing prison populations and declining non-violent prison populations.

I wonder if rolling in federal inmates would change the percentages much.

Corrections-in-the-United-States_0442512_21

no hint of opinion here

SecondOpinion400From an article about a new report on medications for opiate treatment:

The report also examined studies that evaluated buprenorphine, methadone, injectable naltrexone, and oral naltrexone and concluded a benefit in patient outcomes as well as costs.

“I can say with no hint of opinion here, it’s simple fact, they are all effective,” McLellan said. “They’re effective not just in reducing opioid use, they’re effective in so many other ways that are important to societies and families.”

Effective. It’s a fact. No opinion here. Hmmm.

Effective at what? These drugs are effective at reducing opiate use. If that outcome is all one wants, they may be a good option.

The problem is that it’s a palliative response, when we know that full recovery is possible if the right resources are made available. (Of course these treatment approaches are not the ones physicians choose for themselves and their peers.)

Let’s see what the report says about another outcome that might speak more directly to quality of life, say, employment [emphasis mine]:

These studies have also measured various types of related outcomes such as reductions non-opioid drug use, employment and criminal activity. Here the literature is quite mixed and appears to be a result of the particular patient population, the clinical approach of the methadone maintenance program and the available counseling and social services provided.

and

As with methadone, the literature is quite mixed with regard to reducing non-opioid drug use, improving employment and reducing crime.

and

He also found improvements within the methadone maintenance group across various time periods on HIV risk behaviors, employment and criminal justice involvement. [My note: In this study, employment increased from approximately 21% to approximately 31%*.]

So…while there’s little doubt that these medications reduce opiate use and overdose deaths, the quality of life evidence is considerably weaker.

With the increases in opiate ODs, I understand families and individuals struggling with these decisions. I struggle to come up with the best analogy for informed consent. Maybe something like this?

Maybe the choice is something like a person having incapacitating (socially, emotionally, occupationally, spiritually, etc.) and life-threatening but treatable cardiac disease. There are 2 treatments:

  1. A pill that will reduce death and symptoms, but will have marginal impact on QoL (quality of life). Relatively little is known about long term (years) compliance rates for this option, but we do know that discontinuation of the medication leads to “near universal relapse“, so getting off it is extremely difficult. The drug has some cognitive side-effects and may also have some emotional side effects. It is known to reduce risk of death, but not eliminate it.
  2. Diet and exercise can arrest all symptoms, prevent death and provide full recovery, returning the patient to a normal QoL. This is the option we use for medical professionals and they have great outcomes. Long-term compliance is the challenge and failure to comply is likely to result in relapse and may lead to death. However, we have lots of strategies and social support for making and maintaining these changes.

The catch is that you can’t do both because option 1 appears to interfere with the benefits of option 2.

CORRECTION: This post originally stated that the Anglin study found an increase in employment from 21% to 21%. It has been corrected to 21% to 31%.

UPDATE: I added the following to option 1 –  but we do know that discontinuation of the medication leads to “near universal relapse“, so getting off it is extremely difficult.

Alcohol’s place in our culture

A Kranz (wreath) of Kölsch beer.
A Kranz (wreath) of Kölsch beer. (Photo credit: Wikipedia)

Following up on yesterday’s post, a few articles jumped out at me.

First, the Michigan legislature is considering lowering the blood alcohol level for boats and other recreational vehicles to 0.08, so that it matches the BAL for driving a car. Sorta makes sense, right? Look at the comments in the Detroit Free Press and the Detroit News. Yikes. Being allowed to drink to the point of impairment and still legally drive a boat is really important to us.

The other thing that caught my attention was another exchange from the interview I linked to yesterday with Kleiman:

Matthews: Roughly how much of the crime problem would you attribute to alcohol, percentage-wise?

Kleiman: Half the people in prison were drinking when they did whatever they did…Of the class of people who go to prison, a lot of them are drunk a lot of the time. So that doesn’t mean that they wouldn’t have done it if they had not been drunk. It’s just that being drunk and committing burglary are both parts of their lifestyle. Still, alcohol shortens time horizons, and people with shorter time horizons are more criminally active because they’re less scared of the punishment. Most people who drive drunk are sensible enough to know when they’re sober that they shouldn’t be driving drunk. It’s only when they’re drunk that they forget they’re not supposed to drive drunk.

We need to keep them from drinking, which is what the 24/7 program does. We could also require everyone to be carded. Maybe you still get carded, but I don’t. But imagine everyone got carded, and if I had a DUI, I had a driving license showing I wasn’t allowed to buy a drink. You’d make the alcohol industry regulate its own customers. And I think you’d cut down on crimes substantially. But if I say that, I’m a nanny state fanatic, and if I say adults should be allowed to smoke a little bit of pot, I’m a crazy drug reformer.

This guarding of alcohol’s place in our culture puts us in some pretty crazy knots, huh?

Human rights and coerced treatment

 

Superior Court Judge Jason Deal, right, congratulates one of three graduates, who successfully completed Dawson County’s Drug Court.

A recent article looks at the ethics and effectiveness of coerced treatment:

It has been argued that quasi-compulsory treatment (QCT) may be considered ethical (under some specific conditions) for drug dependent offenders who have committed criminal offences for whom the usual penal sanction would be more restrictive of liberty than the forms of treatment that they are offered as a constrained, quasi-compulsory choice. It has briefly reviewed research that suggests that QCT may be as effective as treatment that is entered into voluntarily. This may help individuals to reduce their drug use and offending and to improve their health, but it is unlikely to have large effects on population levels of drug use and crime.

Criminal charges before and after initiation of buprenorphine maintenance

I would have thought this was a softball in support of buprenorphine. But, no:

Among subjects with prior criminal charges, initiation of office-based buprenorphine treatment did not appear to have a significant impact on subsequent criminal charges.

The paper gets a little says that this lack of effect includes drug charges. I’m no fan of buprenorphine maintenance and even I’m surprised.