Their every truth . . .

…most men have bound their eyes with one or another handkerchief, and attached themselves to some one of these communities of opinion. This conformity makes them not false in a few particulars, authors of a few lies, but false in all particulars. Their every truth is not quite true. Their two is not the real two, their four not the real four: so that every word they say chagrins us and we know not where to begin to set them right. ~ Emerson

Now the Huffington Post frames people with a preference for abstinence-based recovery as anti-science and backward. Ugh!

How bad is this article? Let me count the ways.

One: They use a variation of the “some people say” tactic (emphasis mine):

Many in the medical establishment oppose the abstinence model — as do officials at the Centers for Disease Control and Prevention and the Substance Abuse and Mental Health Administration

Really? Then why do they treat their colleagues with an abstinence-based approach? Actually, they go even further, requiring that their colleagues be treated with an abstinence-based approach. (And, they are very successful with this abstinence-based approach.)

Two: They abandon the “some people” qualifier and frame advocates of abstinence-based recovery as irrational zealots.

Advocates of the abstinence model consider the use of Suboxone or methadone to be tantamount to using heroin itself.

What serious person says it’s equivalent to using heroin? This is a straw man.

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Three: They they say abstinence-based approaches cost lives.

. . . a recent Huffington Post investigation found that the bias in favor of abstinence is costing the lives of those it regularly fails.

I posted about that investigation and its problems earlier.

I’ve also posted about a study finding high mortality rates among methadone patients in Australia. (6.5 times higher than the general population with an average of 44 years of potential life lost for each fatality.)

There’s no doubt that being on an opiate replacement drug reduces overdose risk, but only if they take the drug and those drugs have big patient retention problems too. (Here, here, herehere and here.)

Four: They then use relapse rates against abstinence-based treatment:

Over 90 percent of people treated with the abstinence method will relapse.

Note that there is no source and they are holding methadone and abstinence-based treatment to different standards. They don’t report on relapses for drug maintenance patients because studies of maintenance drugs tend to look for reductions in illicit drug use rather than abstinence.

As I recently wrote, the treatment system is failing opiate addicts, but the problem isn’t abstinence-based treatment. It’s the failure to provide treatment of the adequate duration, intensity and quality. In fact, when patients get good care of the adequate intensity and duration, they do very well.

Five: They seek comments from Bankole Johnson, a treatment critic, medication investor and researcher who failed to report conflicts of interest in a timely manner and left one job after losing a whistleblower lawsuit.

Six: They inserted an inane poll asking:

. . . whether it’s more effective for heroin addicts to detox completely and attend Narcotics Anonymous meetings, or for them to receive synthetic opiates under medical supervision . . .

This question feels like a setup. Detoxing addicts and sending them to NA is bad care. And, almost every expert agrees that just giving addicts maintenance drugs is bad care. So, those who are polled are given two bad options and then treated as ignorant because of their answer.

Seven: Then they insert partisan politics into they equation by breaking down responses by Republicans and Democrats. I’ve wondered before whether these attacks on abstinence-based treatment and recovery are part of the culture wars. This would seem to support that notion.

I have more problems with this series of articles that don’t rise to the level of the problems above.

First, the article reports that maintenance drugs are the standard of care in the rest of the developed world. This is largely true, but some countries are re-evaluating their approach. Also, we’ve developed relationships with Japanese treatment providers and addicts and have learned that addicts there believe that maintenance approaches failed them focusing on stability over quality of life.

Second, as mentioned above, these articles fail to acknowledge the success of health professional, lawyer and pilot recovery programs. These programs are abstinence-based, we researched and have very high long term success rates.

Third, these articles make it sound as though relatively few addicts have access to these drugs. Suboxone is the number 39 drug in the US and has sales of more than $1.4 billion. Further, a federal surveys find that ORT admissions accounted for 26% of all admissions. [Not 26% of opioid addiction admissions. 26% of all addiction treatment admissions.]

Finally, this series fails wrestle with the evidence in any meaningful way and the writers fail to ask themselves why reasonable people might prefer abstinence as a goal.

They are correct that there is a lot of evidence for these drugs reducing drug use, crime, disease transmission and overdose. However, reduce is an important word. Most people don’t want reduced drug use, they want full participation in family, professional, community and academic life. Despite the writers’ enthusiasm for maintenance drugs, they do not have an evidence-base for that kind of recovery.

None of this is to say that the treatment system isn’t broken, or that people who want them shouldn’t have access to maintenance drugs. It’s just to say we shouldn’t oversell maintenance approaches and describe abstinence-based approaches as “broken” when the real problems are the quality, dose and duration.

Drug courts and the “wonder drug”

keep-calm-and-watch-and-learnAnyone who reads this blog regularly knows that the evidence for Suboxone has been oversold and that it often does not address the real-world goals of most addicts or families. They want recovery–a restoration to wholeness and full participation in all spheres of life over the rest of their lifespan. The evidence base for maintenance drugs tends to focus on short term outcomes and on reductions in overdose, disease transmission and criminal justice involvement.

That said, I’ve made it plain that I’m not interested in taking options away from patients, especially well-informed patients.

Along comes this news that the new drug czar is going to require drug courts receiving federal funds allow the use of maintenance drugs. (Under the headline. “Wonder Drug” at Slate.)

It’s got maintenance treatment and harm reduction advocates whoop-whoop-ing. It’s got abstinence-based recovery advocates concerned.

The article begs a lot of questions. For example,

  • If “doctors and scientists view [these drugs] as the most effective care for opioid addicts”, why aren’t more doctors willing to prescribe it? And, why don’t they use these drugs with their addicted colleagues?
  • Why do the authors fail to acknowledge the longer term studies that find poor retention of patients on Suboxone? (Here, here, here, here and here.)
  • How did these “medications, when combined with other behavioral supports” become “the standard of care for the treatment of opiate addiction” when studies have found that people on maintenance medications do not benefit from additional behavioral therapy? (Here, here, here and here.)

However, as a policy matter, given the context within the field, this move makes sense.

Drug courts have sought more than reduced criminal activity. They’ve looked for the same kind of transformational recovery that families often seek. Maybe it’s appropriate for the feds to take these steps. I don’t have any strong feelings about it.

However, this is going to be a very good opportunity to learn a lot about the effectiveness of Suboxone over 12 to 24 months.

  • What will happen when you prescribe it to patients who are in a system that provides long term and robust recovery monitoring with enforced abstinence from illicit drugs and participation in behavioral treatment/support?
  • Will patients want to stay on the drug?
  • If not, will courts treat the decision to discontinue maintenance as non-compliance with treatment?
  • How will improvements in quality of life measures for these participants compare to other participants?
  • Will they experience the same benefits from the behavioral interventions that other participants do?