Most popular posts of 2015 – #9 – Opiate-addicted Parents in Methadone Treatment: Long-term Recovery, Health and Family Relationships

LrgWord_FamilyI recently came across this 10 year follow-up of parents in methadone treatment and their children from 2011.

Here’s a review of their outcomes.

First, here’s their definition of recovery:

Recovery status was based on recent drug use, history of drug problems, and history of incarceration. Long-term recovery was defined as no recent drug use (self-report or urinalysis [UA]) and no drug problems or incarcerations for at least 10 years (LHC data). Moderate recovery was defined as no recent drug use and no history of drug problems or incarcerations in the past 5 years.

Here are the outcomes for their definition of recovery:

Of the 144 parents in the original study, 34 (24%) had died. Nineteen (13.2%) appeared to meet our criteria for recovery for at least 10 years. Another 14 (9.7%) met these criteria for 5 to 10 years. Ten (7%) could not be characterized on recovery because they could not be located or contacted. The remaining 46% of the original sample did not meet our criteria for recovery because they experienced continuous or intermittent drug use or incarceration.

If that definition of recovery is a little too muddy for you, here’s some of the data on drug use.

Of the parents who reported no drug problems in the past 10 years (n = 37), over a third (n = 16) self-reported using illegal drugs in the previous 30 days and did not consider this a problem. Forty-nine percent of parents interviewed reported some illegal drug use in the past 30 days

Did they stay in treatment over the 10 years?

Forty-one percent of the parents reported participating in some form of drug treatment every year, and 32% were in methadone treatment every year. Methadone treatment was intermittent for 43% of the sample.

What about criminal justice involvement?

Arrests and convictions were common (90% had some WA state criminal record in the past 10 years), and periods of incarceration over the last 10 years were reported by 54% of parents interviewed, compared to a lifetime prevalence rate of arrests in the United States of 3%.

Mortality?

Mortality among the addicted parents was high. Thirty-two (25%) of the 130 families experienced the death of the addicted parent, and in 2 cases both parents had died before the long-term follow-up interview (34 deaths total). For comparison, mortality in the general population of Washington State was 7.5% 25in 2005 and 14.8% among heroin users in the Seattle metropolitan area.

Mental health?

Mental health was also compromised. Forty-eight percent met DSM III criteria for a major depressive disorder in the last 10 years. . . .  Twenty-one percent felt their mental health was not good every day (mean days = 12.47, SD = 11.53). This is a high compared to the general population in Washington (mean days of mentally unhealthy days = 3.3).

Employment?

Unemployment was common. At the time of the interview, 52% reported no employment in the past year (55% of women and 40% of men, NS), compared to the unemployment rate for Washington State, which was 5.5% in 2005.29 Forty-one respondents (35 women, 6 men, NS) reported no time in the past 10 years in which they were employed more than 30 hrs/week for at least 9 months.

Stable housing?

Thirty-six percent reported at least one year in which they did not have a regular place to live. There were no differences by gender. Four parents reported being homeless during the entire 10-year period and were homeless at the time of the long-term follow-up interview. Parents in long-term recovery were less likely to report homelessness (5.3%) compared to those in shorter term recovery (35.7%) or those still using (44.8%, X2 = 10.0, p = .007).

The experience of the kids?

Overall, however, this study fills an important gap in the literature by providing a window into the lives of parents struggling with drug addiction. Our study shows similar negative long-term outcomes for opiate-addicted parents in methadone treatment as other studies have found for more general populations of drug addicts and methadone clients.

. . .

Very few of the children were doing well at the long-term follow-up. As previously reported,9 only 24% of the children met criteria for functional resilience by being constructively engaged in school or work, not having abused drugs, and avoiding criminal charges in the last 5 years.

Keep in mind that this is the treatment frequently referred to as the “most effective” treatment. You should ask, “Compared to what? And, as for what outcome measure?”

Further,  recent media coverage of the issue paints anyone who raises these kinds of questions as out-dated, moralistic, simple-minded and one-wayers. Some coverage comes close to implying that anyone who questions ORT is enabling overdose deaths.

I’m not saying a reasonable person could not reach a different position than I have. But, I have a hard time understanding how a reasonable person could be so certain that they try to dismiss, censor and discredit others by questioning their ethics, intelligence and motives.

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.

Opiate-addicted Parents in Methadone Treatment: Long-term Recovery, Health and Family Relationships

LrgWord_FamilyI recently came across this 10 year follow-up of parents in methadone treatment and their children from 2011.

Here’s a review of their outcomes.

First, here’s their definition of recovery:

Recovery status was based on recent drug use, history of drug problems, and history of incarceration. Long-term recovery was defined as no recent drug use (self-report or urinalysis [UA]) and no drug problems or incarcerations for at least 10 years (LHC data). Moderate recovery was defined as no recent drug use and no history of drug problems or incarcerations in the past 5 years.

Here are the outcomes for their definition of recovery:

Of the 144 parents in the original study, 34 (24%) had died. Nineteen (13.2%) appeared to meet our criteria for recovery for at least 10 years. Another 14 (9.7%) met these criteria for 5 to 10 years. Ten (7%) could not be characterized on recovery because they could not be located or contacted. The remaining 46% of the original sample did not meet our criteria for recovery because they experienced continuous or intermittent drug use or incarceration.

If that definition of recovery is a little too muddy for you, here’s some of the data on drug use.

Of the parents who reported no drug problems in the past 10 years (n = 37), over a third (n = 16) self-reported using illegal drugs in the previous 30 days and did not consider this a problem. Forty-nine percent of parents interviewed reported some illegal drug use in the past 30 days

Did they stay in treatment over the 10 years?

Forty-one percent of the parents reported participating in some form of drug treatment every year, and 32% were in methadone treatment every year. Methadone treatment was intermittent for 43% of the sample.

What about criminal justice involvement?

Arrests and convictions were common (90% had some WA state criminal record in the past 10 years), and periods of incarceration over the last 10 years were reported by 54% of parents interviewed, compared to a lifetime prevalence rate of arrests in the United States of 3%.

Mortality?

Mortality among the addicted parents was high. Thirty-two (25%) of the 130 families experienced the death of the addicted parent, and in 2 cases both parents had died before the long-term follow-up interview (34 deaths total). For comparison, mortality in the general population of Washington State was 7.5% 25in 2005 and 14.8% among heroin users in the Seattle metropolitan area.

Mental health?

Mental health was also compromised. Forty-eight percent met DSM III criteria for a major depressive disorder in the last 10 years. . . .  Twenty-one percent felt their mental health was not good every day (mean days = 12.47, SD = 11.53). This is a high compared to the general population in Washington (mean days of mentally unhealthy days = 3.3).

Employment?

Unemployment was common. At the time of the interview, 52% reported no employment in the past year (55% of women and 40% of men, NS), compared to the unemployment rate for Washington State, which was 5.5% in 2005.29 Forty-one respondents (35 women, 6 men, NS) reported no time in the past 10 years in which they were employed more than 30 hrs/week for at least 9 months.

Stable housing?

Thirty-six percent reported at least one year in which they did not have a regular place to live. There were no differences by gender. Four parents reported being homeless during the entire 10-year period and were homeless at the time of the long-term follow-up interview. Parents in long-term recovery were less likely to report homelessness (5.3%) compared to those in shorter term recovery (35.7%) or those still using (44.8%, X2 = 10.0, p = .007).

The experience of the kids?

Overall, however, this study fills an important gap in the literature by providing a window into the lives of parents struggling with drug addiction. Our study shows similar negative long-term outcomes for opiate-addicted parents in methadone treatment as other studies have found for more general populations of drug addicts and methadone clients.

. . .

Very few of the children were doing well at the long-term follow-up. As previously reported,9 only 24% of the children met criteria for functional resilience by being constructively engaged in school or work, not having abused drugs, and avoiding criminal charges in the last 5 years.

Keep in mind that this is the treatment frequently referred to as the “most effective” treatment. You should ask, “Compared to what? And, as for what outcome measure?”

Further,  recent media coverage of the issue paints anyone who raises these kinds of questions as out-dated, moralistic, simple-minded and one-wayers. Some coverage comes close to implying that anyone who questions ORT is enabling overdose deaths.

I’m not saying a reasonable person could not reach a different position than I have. But, I have a hard time understanding how a reasonable person could be so certain that they try to dismiss, censor and discredit others by questioning their ethics, intelligence and motives.

Stuck on Methadone

billboard-stuck_1116867iDJ Mac reviews a recent German paper looking into why patients stay on methadone. His review is easily the best post I’ve read on the complicated relationship between methadone and recovery. Read the whole post.

The paper’s starting point:

The paper outlines that retention in ORT is not great, with just over half of patients sticking with methadone and fewer with Suboxone. Despite this, in Berlin, as we have said, there are growing numbers of people on ORT. These are people who are not moving on; I suppose the ones the press call ‘parked’ on methadone. Hence the question the authors pose: “Why is this?”

Their findings:

  1. Both patients and staff thought ORT helped physical and mental health. Beneficial effects of ORT on the ability to work and on crime were considered significantly higher by patients compared to staff.
  2. Staff and patients agreed that coming off ORT was hard. Patients thought it harder than coming off heroin.
  3. Patients wanted to eventually come off ORT at a significantly higher rate than staff estimated.

. . .

The thing that intrigues me the most is the “striking discrepancy between the patients’ and staff members’ assessment of the patients’ desire to end OMT on the long term. The large majority of patients report the desire to end OMT on the long term, whereas only a minority of staff members believe that their patients might really have such a desire.”

David Best found much the same thing (in aspirational terms) in a sample of drugs workers in the UK. They believed only 7% of their clients would eventually recover.

DJ Mac’s take:

It’s clear to me that where there is such a mismatch, when the bar is set so low and when there is little hope pervading treatment settings, then it’s no wonder that so few move on.

By the conclusion the authors find themselves at odds with the assertion at the start of the paper (that ORT has an aim of ‘abstinence from opioids’.) Here’s what they say (my emphasis):

“Finally, detoxification of OMT is not the prime objective of treatment. The prime objective of treatment is continued physiological and social stabilization. As yet, there is no validated medical cure for opioid addiction. Until a curative medication or a safe curative procedure is developed, many of the patients may have to remain in treatment for the duration of their lives to avoid relapses, increased criminality, subsequent overdoses, and death during the post treatment period.”

So the solution to the mismatch between the low expectation of staff and the higher expectation of patients is to lower the expectation of patients to that of staff?

It’s clear that issues identified in this paper are not isolated. They report on the patient experience in Germany. It resonates with DJ Mac in the Scotland. And, it resonates with me, here in the states. (Methadone’s problems in the US are often attributed to a system that’s dominated by abstinence-oriented providers who stigmatize ORT. That can’t be said of the other countries.)

The post, to my mind, ended up being a great informed consent document on one of the more concerning hazards of ORT.

Read the whole thing here.

Buprenorphine Overseas

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“The history of the treatment of narcotic withdrawal is a long and dishonorable one. The trail is strewn with cures enthusiastically received and then quietly discarded when they turned out to be relatively ineffective or even worse, productive of greater morbidity and mortality… Any claim for a new method should be put forward modestly and viewed with skepticism until amply documented by careful experimental procedures.” Herbert Kleber (1982)

A couple of interesting articles about buprenorphine overseas hit my inbox recently.

First, from Finland [emphasis mine]:

Young women are at particular risk of death from illicit drug use, according to preliminary results from a major ongoing study by the University of Eastern Finland’s public health department.

The study confirms that drug users have a higher mortality rate than others of the same age, and that this is higher among male users in general. However it finds that women under the age of 25 form an exception. Their risk of death may be as much as 20 times higher than that of non-drug using women in their age group.

The findings are part of a epidemiologic project being carried out in partnership with Helsinki’s Deaconess Institute, Stockholm’s Karolinska Institutet, the Finnish National Institute for Health and Welfare and others. It is a follow-up study of about 5,000 illegal drug users in the Helsinki region who sought treatment at the Deaconess Institute between 1998 and 2008.

10% mortality rate

By the end of 2010, about 500 drug users, or roughly one in 10, had died.

. . .

Relatively few violent ends

Among men, drug-related deaths are more evenly distributed among various age groups. The most common causes are heart attacks and infection. Researchers were surprised that violence seemed to play a marginal role in drug users’ deaths.

Of the approximately 500 deaths, only 14 were attributed to violence – far fewer than from traffic accidents, for instance.

. . .

Subutex and amphetamines most common

Among those seeking help at the Deaconess Institute, buprenorphine has become the most abused drug in the past decade. Marketed for use in heroin treatment, this powerful painkiller is also sold as a street drug. It’s better known under the brand name Subutex.

Next, in the Czech Republic, buprenorphine addiction has become enough of a problem that they are doing research on using methadone and buprenorphine-naloxone to treat buprenorphine addiction. (Yes, you read that right.)

Is this what we want for our family, neighbors, friends, co-workers and country?

Pediatric use of buprenorphine

Adolescent_MedicineDrugfree.org has a piece advocating more use of buprenorphine with children.

Medication-Assisted Treatment (MAT) for opioid dependence is a science-based and proven-effective option for teens and young adults. It should be administered with age appropriate psychosocial therapy and drug testing. Unfortunately, it has been subject to controversy and stigma. Yet the neuroscience of addiction and cravings helps explain why MAT, when properly used and overseen, can be truly life saving for adolescents, young adults, and their families. I see it working all the time. When kids come into treatment, their lives are just chaotic. Parents are desperate — they don’t know what to do or where to turn. The most important thing is to bring stability into the situation, and the best way to do that is with medication.

Ugh!

So now we’re expanding the notion of incapacitating long-term brain changes to adolescents? Who have been using in what quantities? And, for how long? (Apparantly the only people with brains that aren’t permanently disabled by opiate addiction are health professionals. They get abstinence focused treatment and have outstanding outcomes.)

My first thought about the piece was, “Hey, at least he provides some actual numbers.” However, upon closer examination, though the numbers give the appearance of an accountable professional engaging in informed consent, something’s not kosher here.

In our highly-structured program at Boston Children’s Hospital about a third of the children remain completely free from any alcohol and drug use. About another third remain free from opioid use but they might have an occasional slip on alcohol or marijuana. (We tend to not approve of that behavior and keep working with them). And the remaining third, particularly early on, will try opioids once or twice. But even after those early slips they show dramatic improvement over time.

Unfortunately, he doesn’t provide any timeframe. AND, stop and think about the numbers he offered:

  • 1/3 free of alcohol and drug use
  • 1/3 use no opioids but occasionally use alcohol or marijuana
  • 1/3 use opioids “once or twice”

1/3 + 1/3 + 1/3 = 100%

He is saying that approximately 100% will not use opioids 3 or more times? This is an eminent physician at a prestigious institution. He has been a Principal Investigator of studies on adolescent substance abuse funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute on Drug Abuse (NIDA), the Substance Abuse and Mental Health Services Administration, and the Robert Wood Johnson Foundation.

This assertion is so obviously implausible that it should provoke deep skepticism about the people upheld as experts, the funding priorities of government agencies and the biases built into what become “evidence-based practices.” (Remember “no hint of opinion“?)

As you read the comments, you’ll find people complaining about the methadone not being included. (Methadone for adolescents!)

You’ll find one comment, from a physician, explaining that, “Dr. Knight works with adolescents, with most of his patients under age 16, where methadone cannot legally be used (under 18 can be used with parental consent).”

The author’s finger wagging, very certain tone is regarding the use of Suboxone with patients under the age of 16.

I can imagine circumstances where the best path is not crystal clear (I’m thinking of youth that are highly resistant to treatment and at high risk for fatal OD.) but the question any family has to ask is, “How do we want my loved one to return too us?”

Here are Earl Hightower and Anna David:

AD: Should the parents just accept the first recommendation or should they ask for more?
EH: I think the first question they should ask should be one they ask themselves, which is how they want their son to return.

AD: What does that mean?

EH: Well, the majority of the treatment centers out there are 12-step based, which means that the goal for them is for their clients to achieve abstinence. This would be the choice to make if the parents want to get their son back in the same condition that he was in before he got on drugs: drug-free.

AD: But you can’t say for certain that a 19-year-old who was doing Oxy for nine months is definitely an addict who will need 12-step.

EH: You can’t. Maybe he was just dabbling; treatment would be able to help determine that. But maybe treatment will prove something else—maybe treatment will prove that this wasn’t an isolated incident. Maybe he’ll get in there and confess that he’s been using pot since he was 12 and maybe other conversations will turn up the fact that there’s a genetic predisposition toward addiction in the family. And if that’s the case, I believe he will need community-based support in staying clean once he returns home. It could go either way: good ongoing clinical assessment is the backbone of early treatment to determine the direction of care.

AD: But not all rehabs recommend 12-step or even full abstinence.

EH: Yes. And that’s why parents—people—need to know is that if an addict is going to a facility which subscribes to medication-assisted treatment and recovery, the goal is different. Loved ones need to know what medication-assisted treatment really means, which is that treatment will be radically re-defined and their child could be put on a medication which he would remain on for a long time, if not the rest of his life.

AD: So that’s what you mean when you talk about parents asking themselves how they want their child to return.

EH: Yes. But I can tell you from 30 years of doing this work that most parents want their child to come home drug-free—or they at least they want a shot at that. But some members of the treatment community will tell parents—or the addicts themselves—that we have to let go of this notion of abstinence and move more in the direction of medication-assisted treatment. And that means that people who could thrive without being on anything at all are leaving treatment centers on very powerful opiate replacement drugs.

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.

Methadone, technology and outcomes

Substance Matters has a post about the use of new technologies in methadone maintenance.

Patients who use a web-based intervention (TES) instead of half of their traditional counseling did better than those with traditional counseling as part of their methadone treatment.

It provokes important questions about the usefulness of new technologies and how they might be used to improve treatment outcomes.

However, what struck me was this graph:

Web based behavioral treatment for substance use disorders as a partial replacement of standard methadone maintenance treatment

This was a twelve month study. This means that subjects who got TES and did better than subjects recieving traditional methadone used opiates (other than methadone) 25 weeks of the year.

That’s a successful intervention?

 

Methadone with and without counseling

by Fearless Tall Dude Killer
by Fearless Tall Dude Killer

Drug and Alcohol Findings reviews research on the impact of counseling for methadone patients.

While across the board there was significant improvement, being assigned to standard/enhanced versus interim (no counseling) programmes did not further improve retention, illicit drug use and related problems, or make much difference to criminal activity. There was no evidence that interim patients has been substantially disadvantaged by the four-month period during which only emergency counselling was available and during which they could not ‘earn’ take-home doses by providing ‘clean’ urine tests.

The findings are consistent with other studies at typical US methadone clinics. They strongly suggest that rather than making such services obligatory, opioid agonist treatment regulations should allow for additional services where these are both helpful to and wanted by patients. As well as increasing costs by imposing services that may or may not be needed, mandating these services has the unintended consequence of denying access to more basic treatment which is demonstrably of value to patients and to society. The findings also raise questions over discharging patients simply because they have not attended the required number of counselling sessions.

Some of the obvious possible explanations are:

  • Counseling is not effective or necessary with opiate addicts. [But, we know it’s effective with doctors.]
  • Methadone interferes with counseling, possibly leaving patients unavailable for counseling. [There’s some evidence for this with MAT. Here, here, here, here, here and here.]
  • That the dose of counseling methadone patients receive is ineffective. [It seems pretty intuitive that once-a-month counseling is likely to be a sub-therapeutic dose.]

Quality of life and death

English: Graveyard in Barnes
English: Graveyard in Barnes (Photo credit: Wikipedia)

A study out of Australia looks at death rates among opioid addicts receiving opioid substitution treatment (OST, for short. It’s methadone.) in New South Wales between 1985-2005. It’s a HUGE sample–43,789 people. If fact, the paper says:

This cohort is likely to represent the majority of opioid dependent people in that State during this period, perhaps as high as 80%.

To my mind, the strongest argument for methadone and buprenorphine has been overdose prevention–that dead addicts can’t recover and drug-free treatment isn’t going to work for everyone at every point in time. If I’m the parent of a heroin addict and they’ve refused drug-free treatment or relapsed after high quality drug free treatment of the adequate dose and duration, maintenance might look like the least bad option. At least they’ll be alive, right? (Of course, my concern is that these drugs have become the first line treatment and access to better options is diminishing.)

So, what did they find in this cohort?

Well,  8.8% of the cohort died. (9.4% of men.)

There were 3,685 deaths in the cohort between 1985 and 2005 for a crude mortality rate of  894 per 100,000py (95% CI: 865, 923) (Table 1).

How did they die?

The majority of deaths were drug-related  (n=1932; 52%), with most of these (n=1574; 82% of all drug-related deaths) coded as accidental opioid deaths. The bulk of remaining deaths were due to unintentional injuries (n=975; 26% of all deaths) and suicide (n=484; 13% of all deaths).

Did they at least live long lives?

Using the Australian life tables approach, there was an estimated 160,055 Years of Potential Life Lost (YPLL) in this cohort, an average of 44 YPLL per person who died, and 29 years of YPLL before age 65 (Table 4). Just under half (45%) of the YPLL were due to accidental opioid-related deaths (an average loss of 46 years of potential life, or 31 years prior to age 65). Motor vehicle accidents accounted for the highest average YPLL, 47 years, or 33 years before age 65.

How does this compare with the rest of the population?

The overall age-, sex- and year-standardised mortality ratio was 6.5 (95% CI: 6.3-6.7) indicating that our cohort had 6.5 times the rate of mortality than that expected in the population.

Is this unique to Australia?

The average of 44 years of potential life lost for each fatality in the cohort highlights the fact that deaths in opioid users often occur at a young age. This was particularly the case for avoidable causes of death such as drug overdose and injuries. The pattern of YPLL was broadly similar to previous analyses of a Californian male cohort (n=581) in the US, followed from 1962 to 1997 (10). Both studies found that opioid overdoses were the largest contributor to YPLL but suicides made a larger contribution to YPLL in our cohort, and homicide a larger contribution in the Californian cohort.

Now, this doesn’t mean that methadone doesn’t reduce death rates. It means that the death rate is still very high.

It also means that quality of life questions shouldn’t be dismissed with snarky quips like, “What kind of QOL do dead people have?“, because methadone patients die in large numbers too.

If you’re thinking that those were the bad old days, before we had buprenorphine, think again. Retention rates for methadone and buprenorphine are not great. When put head to head, methadone has higher retention rates.

I’ll also throw in a reminder from a previous post about were I stand on ORT:

Just to be sure that my position is understood. I’m not advocating the abolition of methadone.

Here’s something I wrote in a previous post: “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.”

Another: “Once again, I’d welcome a day when addicts are offered recovery oriented treatment of an adequate duration and intensity and have the opportunity to choose for themselves.”

It’s also worth noting that there is a link between AA and methadone.