Optimism? Or, is it low expectations?

Lowering_The_Bar_Cover_2010.09.22The feds recently published an article touting the long-term success of buprenorphine:

In the first long-term follow-up of patients treated with buprenorphine/naloxone (Bp/Nx) for addiction to opioid pain relievers, half reported that they were abstinent from the drugs 18 months after starting the therapy. After 3.5 years, the portion who reported being abstinent had risen further, to 61 percent, and fewer than 10 percent met diagnostic criteria for dependence on the drugs.

These studies are important. Long-term outcomes have been a big gap in the research.

This is great news, right? 50% abstinent at 18 months! 61% abstinent at 3.5 years! Fewer than 10% dependent at 5.5 years!

Wow!

Not so fast

There are a couple of problems here.

  • They were only able to do follow-up with 38% of subjects at 18 months and 52% at 3.5 years.
    • So, that 50% abstinent at 18 months is really more like 19%.
    • The 61% abstinent at 3.5 years is more like 32%

Still, 19% abstinent at 18 months and 32% abstinent at 3.5 years is pretty good, right?

Pump the brakes

There are a couple of problems here too.

  • They are only reporting on abstinence from illicit opioid use, not other drugs.
  • Buried in the article, they mention that they are reporting on being abstinent for the last 30 days. This doesn’t tell us much about how they’ve been doing over the previous 18 months or 3.5 years, does it?
  • Same thing for the reporting on diagnostic criteria for dependence. That was also based only on the previous 30 days.

Taking their conclusions at face value

Further, their conclusions open the door to some interesting questions:

In the first study examining long-term treatment outcomes of patients with prescription opioid dependence, our results were more encouraging than short-term outcomes from POATS suggested. As reported in our 18-month follow-up study (Potter et al., 2014), and consistent with other literature (Moore et al., 2007, Nielsen et al., 2013 and Potter et al., 2013), patients with prescription opioid dependence may have a more promising long-term course, compared with expectations based on long-term follow-up studies of heroin users (Darke et al., 2007, Flynn et al., 2003, Grella and Lovinger, 2011, Hser et al., 2001 and Vaillant, 1973). Indeed, a history of occasional heroin use at POATS entry was the only prognostic indicator 42 months later, associated with a higher likelihood of meeting symptomatic criteria for current opioid dependence. Our results are consistent with research on heroin dependence in supporting the value of opioid agonist therapy for prescription opioid dependence; however, half of the follow-up participants reported good outcomes without agonist therapy.

This begs a couple of important questions.

  • First, many medication assisted treatment advocates have argued that opioid addiction is unique in that it creates long-term or permanent brain dysfunction that requires opioid replacement. Do these findings undermine this theory?
  • Second, half of their follow-up subjects doing well without opioid replacement. Can we assume that opioid replacement is responsible for their good outcomes?

This is the basis for the federal and media push for MAT?

It would appear so.

This not quite what you imagined when they reported 61% abstinent, is it? Why would they present it in a manner that many of us would consider misleading?

It’s also hard to understand their certainty, isn’t it?

I mean, when they talk about this being “treatment that works”, “evidence-based treatment” or “science-based treatment”, don’t most member of the public assume that expressions like “works”, “evidence-based” and “science-based” mean that there’s a body of research indicating that these treatments provide a good chance of getting well?

Instead, these studies suggest that these treatments help make people less sick.

If that’s what patients and their families want, there’s nothing wrong with that. But, they ought to know what they’re getting. (The same goes for communicating the limitations or gaps in evidence for other treatments.)

Don’t believe the hype

hype-marketing

About that Huffington Post article covering Obama’s addiction speech a few weeks ago.

ALLEGATION FACT FACT
A Huffington Post investigation published in January found that the treatment industry overwhelmingly resists a medication-assisted model based on decades-old beliefs about sobriety that have been passed down by those in recovery, but have never been rigorously tested. Suboxone is the number 39 drug in the US and has sales of more than $1.4 billion.* Federal surveys find that opioid replacement treatment (one form of medication assisted treatment) admissions accounted for 27.8%** of all admissions. [Not 27.8% of opioid addiction admissions. 27.8% of ALL addiction treatment admissions.]

More on the Huffington Post’s drug policy reporting here.

* note that this is only for the brand Suboxone and does not include Subutex and generics.

** This post originally reported that maintenance admissions accounted for 26%. It was 26% in 2009. More recent numbers are now available and the updated reports says that maintenance admission accounted for 27.8% of all admission in 2011.

How methadone research works

Start with the premise that opiate addicts don’t get well. (Unless they’re doctors.)

Perform a study offering only two variations of your preferred treatment. (Cheap and crime reducing.) One is high dose or long duration and the other low dose or short duration. Do not offer a recovery oriented option at all, or offer a recovery oriented option of inadequate duration and intensity.

Find that, when offering 2 lousy options, the lousy option with the longer duration or higher intensity reduces symptoms better at follow-up.

Run a headline of, “Methadone Detoxification Remains No Match for Methadone Maintenance, Even with Minimal Counseling.” In the comments, declare, “Methadone maintenance is the preferred treatment approach for heroin dependence.”

Bonus: “No difference between groups was found for cocaine use or depressive symptoms.”

Bonus bonus: “Results for MM with standard counseling (2 hours a month) did not differ from those for MM with minimal counseling (15 minutes a month).”

Question: Do you think this will be used to justify offering even less counseling to methadone recipients?

UPDATE: I got some grief on this post. Here’s my response:

Five points:

  • First, a question. If methadone is a superior treatment option, why don’t they use it for opiate addicted health professionals? Health professionals have high rates of opiate addiction and typically receive long term treatment with monitoring that lasts several years. Treatment is stepped up or down as needed. Guess what? They have great treatment outcomes. You might be inclined to chalk it up to a population with lots of recovery capital. To be sure, that plays a role, but surely a real chronic disease management approach plays a role too.
  • Second, is it coincidence that this study was done on poor black men? Why aren’t studies like this done on young adults from affluent communities?
  • Third, methadone used to be one component of some comprehensive bio-psycho-social treatment programs. I understand that there are still some programs that fit this description, but every program in my area is a dosing clinic and little more.
  • Fourth, regarding misery, notice that there was no difference in depressive symptoms.
  • Fifth, heroin addicts in our long term programs do just as well as everyone else. It’s all about hope and expectations. Beware of the subtle bigotry of low expectations.
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.