Two more defenses of Suboxone

SecondOpinion400In the Washington Post, Harold Pollack interviewed Peter Friedmann about buprenorphine and the NY Times series on buprenorphine.

We’re fortunate that that they share their premises.

HP: Buprenorphine provides a “substitution therapy” for people with opiate disorders.

PF: Correct. For many years, opiate addiction was considered an incurable illness. It was Dole and Nyswander in New York who proposed that we might stabilize the social and physiologic effects of opiate addiction by administering a long-acting oral, preferably an oral agent, for substitution therapy.

postcard---heroin-lie

incurable” until Dole and Nyswander proposed methadone substitution. That’s their premise.

Though we disagree on a lot, we share one big concern. I’ve long expressed concern that the Affordable Care Act will shift the locus of care to primary care offices.

We have to decide what we’re trying to do here. Is this like treating simple hypertension, or is this like treating somebody who’s having a myocardial infarction. We don’t treat heart attacks in primary care. People with severe disorders need better access to good care. Some people with fairly mild disorders could be treated in primary care, but right now, we don’t have a way to really do this well. Docs have been notoriously resistant to gaining the skills they need to really do this. The hope was that the Drug Abuse Act would push them in this direction. It’s not clear that docs really embraced this change.

Meanwhile, a HuffPost piece trots out the “most effective” argument and then blames some form of puritanism for concern about buprenorphine.

Unfortunately, we cannot seem to free ourselves from our beliefs that addiction is rooted in moral failing or lack of willpower, and that those who use medications, like methadone or buprenorphine, are not truly “clean.”

In truth, we can’t free ourselves from the knowledge that full recovery is possible for any addict. We want more for them than just “reduced opioid abuse, reduced behaviors that put people at risk for HIV or Hepatitis C, and even reduced incarceration.” Maybe the moral reflex isn’t about the addict at all. It could be argued that the moral failing and lack of willpower exists not in the addicts, rather in the system that is generating billions in revenues while failing to provide addicts with the same care that health professionals provide each other.

 

 

without someone like me!?!?!?


Keith Humphreys is pretty great in this interview:

Harold Pollack: I should say you’ve also done some research on AA [Alcoholics Anonymous]. I think some folks would be interested to know that, at least according to your research, AA is actually a pretty impressive intervention in some ways.

Keith: Yeah. I don’t mind people who are skeptical of AA, because when I first heard about it, I thought it sounded kind of hokey. I was in a medical school. I met an AA member, and I was like, “What do you do, exactly?” “We sit around in a room. We talk about spirituality and making amends.” I go, “This is run by a psychologist, a psychiatrist?” He goes, “No, no. There’s no one. It’s just alcoholics.” I, already getting socialized a little into the worst parts of professionalism, had a very dismissive response to that. “My god, without someone like me around, how could you possibly cope with anything?” It’s an attitude that is sadly in medicine, but, like I said, fortunately I wasn’t far enough along in my education that I was incapable of further learning. I was taken to open AA meetings, Cocaine Anonymous, and Narcotics Anonymous meetings in Detroit and in Western Michigan, where I was going to school. I thought, “This is pretty interesting.” I could see that my initial snobbery was not well-founded. It was later, when I started doing prospective studies with good measures and had done some work… with actual randomized clinical trials. Lo and behold, it comes out as well or better as do people like me, who have a lot letters after their name. I’m quite comfortable recommending AA to people as something they should try, as well the other…There are other self-help organizations. It’s incredibly easy to get to. It’s motivating. It’s more fun, I think, than [usual medical treatments]…There’s more friendship than you might get from psychotherapy, something like that. We are social creatures. All the evidence we have shows that social ties are good for health. That’s a way to quickly build up some social capital. I think in the long-term, it helps people not just with their drinking but also with things like friendship. Sometimes job-finding happens in AA, finding someone to marry, all that sort of stuff.

Humphrey’s professional humility stands in sharp contrast with this rant at Mark Willenbring’s blog.

Buried in the report, however, is the shocking statistic that a full 56.4% of the programs (publicly- or privately-funded) prescribed no medications whatsoever.

…while publicly-funded treatment programs were almost 14% less likely to prescribe buprenorphine, only 32.5% of all programs offered the medication. Only 20.6% of programs offered disulfiram, 27% offered tablet naltrexone, 27% offered acamprosate, and a slim 13.1% of programs offered injectable naltrexone….

These findings beg the question: why are evidence-based practices so rare and why is this tolerated in addiction treatment but not in other professional treatments? … When patients are not informed of the full array of treatment options, the lack of informed consent becomes an ethical – and likely legal – issue.

First off, why assume that the absence of meds means that evidence-based practices are absent? (There are lots of non-pharmacological evidence-based practices. )

Secondly, Mark Willenbring himself said:

Occasionally I see patients who have been prescribed acamprosate (Campral) for their alcohol dependence. Campral is the med most likely to be prescribed by general psychiatrists because it was marketed to them. In the US, physicians tend to rely on pharmaceutical representatives too much, as opposed to reading the scientific literature themselves. Unfortunately, I don’t think Campral works. Although a few of the first studies showed very strong effects subsequent studies have not. There now have been three large multi-site studies that have shown no effect of acamprosate, including one in Germany. (There had been speculation that acamprosate worked there because people drank more and they had a month of abstinence in the hospital before starting the drug.)