Tag Archives: Patient

What makes treatment effective?

This will be my post in response to the NY Times’ series on Suboxone.

This post originally ran on 7/19/13 and addressed a lot of our concerns.

*   *   *

postcard---heroin-lie

I’ve been catching a lot of heat recently for posts about Suboxone and methadone. (For the sake of this post, lets refer to them as opioid replacement therapy, or ORT, for the rest of this post.

One commenter who blogs for an ORT provider challenged my arguments that we should offer everyone the same kind of treatment that we offer doctors and questioned the “it works” argument from ORT advocates. He dismissed the treatment model

Another commenter is an opiate addict who objected to a post about Hazelden’s announcement that they started providing ORT maintenance. She reported suffering greatly from cravings and relapsing after drug-free treatment at Hazelden. She’s been on Suboxone for 50 days and feels like it is a better solution for her.

Another post, that has nothing to do with me, blames abstinence-oriented treatment for the recent overdose death of an actor. (Among the other problems with the article are that she slanders abstinence-based treatment by suggesting that abuse is common. She misleads readers into thinking that ORT is not widely available when federal surveys find that ORT admissions accounted for 26% of all admissions. [Not 26% of opioid addiction admissions. 26% of all addiction treatment admissions.]

So, I thought I’d take a step back and try to address the big picture in one post.

The wrong paradigm?

Red_Drug_Pill---recoveryTo some extent, these arguments remind me of hearing Bill White comment on arguments about cognitive-behavioral therapy vs. motivational interviewing vs. 12 step facilitation. He commented that, “these are all arguments within the acute care paradigm.”

I talk often about the success of health professional recovery programs and their remarkable outcomes. What makes these programs so successful? I’d boil it down to a few factors:

  1. They are recovery-oriented. They treat patients with the expectation that they can fully recover and focus on facilitating and supporting recovery rather than just extinguishing symptoms of addiction.
  2. They have a chronic care model. They continue to provide care and support long after the acute stage of treatment (5 years). They also focus on lifestyle changes the will support recovery and look for ways to embed support for recovery in the patient’s environment.
  3. They provide adequate care. The provide multiple levels of high quality care of the appropriate intensity and duration at different stages of the patient’s recovery.

Many abstinence-oriented treatment providers have provided the first, but not the second and third. (Though one could argue that 12 step facilitation offers a long term recovery maintenance model.) They provide 10 days of inpatient care or 2 weeks of intensive outpatient and offer a passive referral to outpatient care. (Only 2% of all treatment admissions were for long term [more than 30 days] residential.) The end product looks something like a system that treats a heart attack with a few days or weeks of emergency care and then discharges the patient with no long term care plan. (Or, a weak long term care plan.) Then, we’re surprised when the patient has another cardiac event.

Many ORT providers have offered the second element, but not the first or third. The long term nature of ORT could be considered a chronic care model. However, the end product look something like palliative care for a treatable condition. It reduces opiate use (not necessarily other drug use), criminal activity and over dose. But these benefits are only realized as long as the patient is on ORT and drop-out rates are not low. And, ORT research has not been able to demonstrate the improvements in quality of life (employment, relationships, housing, life satisfaction, etc.) that we see in those health professionals who get all three elements. (Also note that opiate addicted health professionals often use VERY large doses and go undetected for long periods of time. Any neurological damage from their use does no appear to interfere with their achieving drug-free recovery in very impressive numbers.)

It’s effective!

photo credit: ntoper

photo credit: ntoper

One of the recurring arguments that I hear is that ORT is effective and there is tons of research that it’s effective. I don’t question that it’s effective at achieving some outcomes–reducing criminal activity, reducing opiate use and reducing overdose. If those are the only outcomes you care about, then you can say it’s effective without any qualifications.

Even with my bias for abstinence-oriented treatment, I can imagine circumstances where ORT might be the least bad option. (For example, if your child had been offered high quality treatment of adequate quality and duration more than once and they continue to relapse and be at high risk for fatal overdose.) A few weeks ago I offered an analogy that attempted to offer an approach to informed consent:

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.

Fixing treatment

Hazelden Monument2_2WEBHazelden’s adoption of ORT has provided fuel to a lot of these arguments.

Hazelden was confronted with poor outcomes for their opiate addicted patients. They saw a problem and decided to act.

One option would have been to declare that a 30 day model for opiate addiction treatment is doomed to fail and build a recovery-oriented, chronic care system that delivers high quality care of the appropriate intensity and duration.

ORT seems to be the easier response, particularly with the market and cultural currents flowing in that direction.

Bill White has argued that ORT can be compatible with a recovery orientation. I’m skeptical, but I’m watching and am willing to learn from any success they have.

However, if you can get what the doctor’s having, why would you want anything else? And, shouldn’t we want every patient to get the same kind of care the doctor would get if she were the patient? If you can’t get that, you’ve got some tough decisions to make.

I’m looking for others to implement the health professional model with others, finding ways to build upon it and make it less expensive, as we have.

UPDATE: In an email exchange with a friend who disagrees, I clarified Hazelden’s options, as I see them. If it were Dawn Farm, I’d imagine we’d look at things like:

  • improving our aftercare referral process–asking ourselves if we can make better active linkages to communities of recovery;
  • evaluating whether the intensity, duration and quality of our aftercare recommendations were appropriate;
  • embedding recovery coaching in cities around the country to provide assertive recovery support;
  • improving post-treatment recovery monitoring and re-intervention.

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Filed under Controversies, Dawn Farm, Harm Reduction, Policy, Research, Treatment

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.

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Filed under Controversies, Policy, Research, Treatment

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.]

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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.

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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.

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What makes treatment effective?

postcard---heroin-lie

I’ve been catching a lot of heat recently for posts about Suboxone and methadone. (For the sake of this post, lets refer to them as opioid replacement therapy, or ORT, for the rest of this post.

One commenter who blogs for an ORT provider challenged my arguments that we should offer everyone the same kind of treatment that we offer doctors and questioned the “it works” argument from ORT advocates. He dismissed the treatment model

Another commenter is an opiate addict who objected to a post about Hazelden’s announcement that they started providing ORT maintenance. She reported suffering greatly from cravings and relapsing after drug-free treatment at Hazelden. She’s been on Suboxone for 50 days and feels like it is a better solution for her.

Another post, that has nothing to do with me, blames abstinence-oriented treatment for the recent overdose death of an actor. (Among the other problems with the article are that she slanders abstinence-based treatment by suggesting that abuse is common. She misleads readers into thinking that ORT is not widely available when federal surveys find that ORT admissions accounted for 26% of all admissions. [Not 26% of opioid addiction admissions. 26% of all addiction treatment admissions.]

So, I thought I’d take a step back and try to address the big picture in one post.

The wrong paradigm?

Red_Drug_Pill---recoveryTo some extent, these arguments remind me of hearing Bill White comment on arguments about cognitive-behavioral therapy vs. motivational interviewing vs. 12 step facilitation. He commented that, “these are all arguments within the acute care paradigm.”

I talk often about the success of health professional recovery programs and their remarkable outcomes. What makes these programs so successful? I’d boil it down to a few factors:

  1. They are recovery-oriented. They treat patients with the expectation that they can fully recover and focus on facilitating and supporting recovery rather than just extinguishing symptoms of addiction.
  2. They have a chronic care model. They continue to provide care and support long after the acute stage of treatment (5 years). They also focus on lifestyle changes the will support recovery and look for ways to embed support for recovery in the patient’s environment.
  3. They provide adequate care. The provide multiple levels of high quality care of the appropriate intensity and duration at different stages of the patient’s recovery.

Many abstinence-oriented treatment providers have provided the first, but not the second and third. (Though one could argue that 12 step facilitation offers a long term recovery maintenance model.) They provide 10 days of inpatient care or 2 weeks of intensive outpatient and offer a passive referral to outpatient care. (Only 2% of all treatment admissions were for long term [more than 30 days] residential.) The end product looks something like a system that treats a heart attack with a few days or weeks of emergency care and then discharges the patient with no long term care plan. (Or, a weak long term care plan.) Then, we’re surprised when the patient has another cardiac event.

Many ORT providers have offered the second element, but not the first or third. The long term nature of ORT could be considered a chronic care model. However, the end product look something like palliative care for a treatable condition. It reduces opiate use (not necessarily other drug use), criminal activity and over dose. But these benefits are only realized as long as the patient is on ORT and drop-out rates are not low. And, ORT research has not been able to demonstrate the improvements in quality of life (employment, relationships, housing, life satisfaction, etc.) that we see in those health professionals who get all three elements. (Also note that opiate addicted health professionals often use VERY large doses and go undetected for long periods of time. Any neurological damage from their use does no appear to interfere with their achieving drug-free recovery in very impressive numbers.)

It’s effective!

photo credit: ntoper

photo credit: ntoper

One of the recurring arguments that I hear is that ORT is effective and there is tons of research that it’s effective. I don’t question that it’s effective at achieving some outcomes–reducing criminal activity, reducing opiate use and reducing overdose. If those are the only outcomes you care about, then you can say it’s effective without any qualifications.

Even with my bias for abstinence-oriented treatment, I can imagine circumstances where ORT might be the least bad option. (For example, if your child had been offered high quality treatment of adequate quality and duration more than once and they continue to relapse and be at high risk for fatal overdose.) A few weeks ago I offered an analogy that attempted to offer an approach to informed consent:

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.

Fixing treatment

Hazelden Monument2_2WEBHazelden’s adoption of ORT has provided fuel to a lot of these arguments.

Hazelden was confronted with poor outcomes for their opiate addicted patients. They saw a problem and decided to act.

One option would have been to declare that a 30 day model for opiate addiction treatment is doomed to fail and build a recovery-oriented, chronic care system that delivers high quality care of the appropriate intensity and duration.

ORT seems to be the easier response, particularly with the market and cultural currents flowing in that direction.

Bill White has argued that ORT can be compatible with a recovery orientation. I’m skeptical, but I’m watching and am willing to learn from any success they have.

However, if you can get what the doctor’s having, why would you want anything else? And, shouldn’t we want every patient to get the same kind of care the doctor would get if she were the patient? If you can’t get that, you’ve got some tough decisions to make.

I’m looking for others to implement the health professional model with others, finding ways to build upon it and make it less expensive, as we have.

 

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Filed under Controversies, Dawn Farm, Harm Reduction, Policy, Research, Treatment

Why “medical” marijuana gets little respect here

English: Discount Medical Marijuana cannabis s...

Discount Medical Marijuana cannabis shop, Denver, Colorado. (Photo credit: Wikipedia)

 

Mark Kleiman, the Washington state pot czar,  explains his use of “scare quotes” when writing about medical marijuana:

 

Yes, cannabis has medical value for some people. And yes, the sustained effort of the federal government to make medical cannabis research as difficult as possible is a national disgrace.

And then, on the other hand, there’s this, from a report of the Colorado State Auditor:

As of October 2012, a total of 903 physicians had recommended medical marijuana for the 108,000 patients holding valid red cards. Twelve physicians recommended medical marijuana for 50 percent of those patients, including one physician with more than 8,400 patients on the Registry.

Some physicians have recommended what appear to be higher-than-reasonable amounts of medical marijuana. In one case, a physician recommended 501 plants for a patient. In another case, a physician recommended 75 ounces of useable marijuana for the patient.

Do the arithmetic on 8400 patients for one physician. Assume a 50 40-hour workweeks and zero time spent on administrative tasks. That’s a little bit less than 15 minutes per customer. Medical practice? No. Just dope dealing.

 

He adds:

 

The strategy of using quasi-medical legalization as a means of normalizing consumption and moving the political acceptability of full commercial legalization has been a great success … And I’m not unhappy with the outcome. … Still, the whole deal – and especially the role of the “kush docs” – makes me a little sick to my stomach.

 

 

 

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