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.

 

 

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.

 

Buprenorphine compliance rates

Choose you evidence carefully by rocket ship
Choose you evidence carefully by rocket ship

The following abstract popped up today.

The purpose of the study was to look at factors associated with completion of the 6 month, primary care based program.

What struck me was the completion rate–35.7%. For all the crowing about ORT, this seems really low. (And, they said this completion rate is consistent with prior studies.) This is particularly underwhelming when the researchers identify physical injury as a predictor of completions and speculate that this is related to chronic pain. These subjects constitute 71.7% of completers. So…when you omit those with injuries, the completion rate drops to 24%.

Primary care patient characteristics associated with completion of 6-month buprenorphine treatment

BACKGROUND: Opioid addiction is prevalent in the United States. Detoxification followed by behavioral counseling (abstinence-only approach) leads to relapse to opioids in most patients. An alternative approach is substitution therapy with the partial opioid receptor agonist buprenorphine, which is used for opioid maintenance in the primary care setting. This study investigated the patient characteristics associated with completion of 6-month buprenorphine/naloxone treatment in an ambulatory primary care office.
METHODS: A retrospective chart review of 356 patients who received buprenorphine for treatment of opioid addiction was conducted. Patient characteristics were compared among completers and non-completers of 6-month buprenorphine treatment.
RESULTS: Of the 356 patients, 127 (35.7%) completed 6-month buprenorphine treatment. Completion of treatment was associated with counseling attendance and having had a past injury.
CONCLUSIONS: Future research needs to investigate the factors associated with counseling that influenced this improved outcome. Patients with a past injury might suffer from chronic pain, suggesting that buprenorphine might produce analgesia in addition to improving addiction outcome in these patients, rendering them more likely to complete 6-month buprenorphine treatment. Further research is required to test this hypothesis. Combination of behavioral and medical treatment needs to be investigated for primary care patients with opioid addiction and chronic pain.

“It works!”, Ctd

This is "effective"?
This is “effective”?

A new study of buprenorphine implants find that implants work as well as oral dosing and outperform placebo.

What does that mean?

If I’m reading it correctly, it means that the average subject receiving the implant tested positive for opioids 68.8% of the time compared to 86.6% for the placebo subjects. (If I’m misreading it, set me straight.)

I don’t know about you, but that not how I’d define success for myself or a family member.

This speaks directly to the importance of asking, “what does ‘effective’ mean?”

Another article argues for morphine maintenance for opioid addiction.

If ORT is the direction the field is heading, why not? If questioning the assertion that ORT is the most effective treatment based on quality of life differences is a bogus argument*, why not morphine maintenance or heroin maintenance?

*  Note that I’ve argued that physicians health programs are the gold standard and that they should replicated and offered to all opioid addicts. I did not say that they standard abstinence-based treatment was superior or should be imposed on anyone. In fact, I’ve repeatedly argued that the standard abstinence-based treatment offered opioid addicts does not provide the appropriate quality, duration, intensity or dose.

Buprenorphine + therapy = ?

Red_Drug_Pill---recoveryIan McLoone directs us to another study (the 4th in a row) finding that buprenorphine patients receive no benefit from added behavioral treatments.

Where does this leave us?

We’ve seen criticism of the devolution of methadone maintenance (MMT) into dosing clinics with calls for a new recovery orientation to MMT and a return to methadone being one element of a comprehensive bio-psycho-social treatment program.

I’m also reminded of this quote from a methadone advocate:

All chronic diseases have a behavioral component, and that’s what you’re dealing with—a chronic disease. The problem with the methadone community is we have too many people who think methadone is a magic bullet for that disease—that recovery involves nothing more than taking methadone.

This view is reinforced by people who, with the best of intentions, proclaim, “Methadone is recovery.” Methadone is not recovery. Recovery is recovery. Methadone is a pathway, a road, a tool. Recovery is a life and a particular way of living your life. Saying that methadone is recovery let’s people think that, “Hey, you go up to the counter there, and you drink a cup of medication, and that’s it. You’re in recovery.” And of course, that’s nonsense. Too many people in the methadone field learn that opiate dependence is a brain disorder, and they think that that’s all there is to it. But just like any other chronic medical condition, it has a behavioral component that involves how you live your life and the daily decisions you make.

If opioid replacement therapy (or medication-assisted treatment) should be more than just taking medication, and the medication appears to interfere with the effectiveness of the behavioral treatments*,  where does that leave us? What is it about the drug that interferes? (Earlier this week I posted a link to a study the found blunted emotional responses in buprenorphine patients. Previous studies have found impaired cognitive function.)

Also, keep in mind that the drug use outcomes this study focused on were 3 consecutive negative drug screens, 6 consecutive negative drug screens and the average number of negative drug screens. These outcomes measures tell us something, but these are not the outcomes that addicts and their families will measure their success by. At the same time, subject satisfaction rates with buprenorphine were very high. (85%)

How can you build a recovery-oriented treatment model, when the patient is somehow rendered immune to our other tools?* Will they benefit from mutual aid? Does whatever’s going on impact quality of life?

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.

* See this point discussed in the comments below.

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.