NY Times on Medicines to Keep Addiction Away . . . “these work”

The NY Times has a new post on “Medicines to Keep Addiction Away“.

The writer makes some pretty strong statements. Here she is on  methadone and buprenorphine:

These work. (See here, here and here, just some of many studies). They reduce illicit drug use and keep people in treatment, compared with recovery programs that don’t include medicine. These medicines also cut the risk of fatal overdose by half. I’ll repeat: People on these medicines were half as likely to die of overdose as those getting psychological or social interventions alone

“These work.”

Let’s pick this apart. “These work.”

What does “work” mean? Well, she provides 3 references. Let’s go to her evidence.

Reference 1: Let’s go straight to the author’s conclusion.

Methadone is an effective maintenance therapy intervention for the treatment of heroin dependence as it retains patients in treatment and decreases heroin use better than treatments that do not utilise opioid replacement therapy. It does not show a statistically significant superior effect on criminal activity or mortality.

Reference 2: They looked at studies measuring treatment retention and suppression of illicit opioid use. It appears the medications did improve retention and reduce illicit opioid use. However, methadone was more effective than buprenorphine. Why? Here’s what the authors hypothesized.

It is the authors’ view based on clinical experience that the user misses the “gouch” (the colloquial term in the UK coined by users for the slight “head-nodding” effect of heroin and methadone) associated with methadone compared with the relatively “clear-headed” state associated with buprenorphine, and this plays a significant role in the relative lack of uptake of the latter.

Reference 3: They summarized their findings as follows:

Buprenorphine Maintenance Treatment has a positive impact compared with placebo on:

• Retention in treatment
• Illicit opioid use

Evidence is mixed for its impact on:

• Nonopioid illicit drug use

Retaining people in treatment is a good thing, right? If we can keep them in treatment it gives us the chance to use psychosocial interventions, exposing them to social workers, other helpers and peers that can help them improve their quality of life. Right?

Not so fast. Here’s what reference 3 has to say about that:

The addition of structured psychotherapy to standard treatment—which may include peer support services, 12-step programs, and other psychosocial treatment provided at the facility or office—has not been shown to improve outcomes for patients on opioid maintenance therapy.

So . . . according to the author’s evidence, “works” means:

• we can expect patients to use fewer illegal opioids;
• they will keep coming back for their buprenorphine or methadone;
• a stronger “head-nodding” opioid effect predicts better retention and less illegal opioid use;
• maybe they’ll use fewer nonopioid illegal drugs; and
• somehow, they’ll be maintained in a state where they are not helped by additional psychosocial interventions.

Are these outcomes what we want for our opioid addicted loved ones? Would achieving those outcomes for your son/daughter be a success?

half as likely to die

There’s little argument that maintenance drugs reduce risk of overdose. It’s less clear how big that reduction is, especially when asking the questions, “compared to what?” and “over what period of time?”

The author makes a pretty bold claim that these medication reduce death by 50%. That’s huge!

What’s her evidence? She uses an English study with an impressively large n of 191,310 patients. And, it compares methadone (not buprenorphine) to residential treatment. That residential to methadone comparison sounds promising. However, I was unable to find any information about the duration of residential treatment and the kind of recovery support that patients received following residential. (That’s a big gap in the information we’d need to make meaniningful inferences from the study. But, let’s put that aside for now.)

More importantly, there’s one issue that raised my eyebrow. The researchers did indeed find a fatal overdose rate of half for methadone recipients when compared to residential treatment patients. However, if I’m reading the study correctly, the total number of post-treatment fatal overdoses for patients discharged from residential treatment was 10. 

Doesn’t that seem like an awfully small number of fatal overdoses to draw such a strong conclusion from?

And, the evidence she used to support her “that works” argument said this, “[methadone] does not show a statistically significant superior effect on criminal activity or mortality.”

Mortality can include causes of death other than fatal overdose. Interestingly, another study that measured mortality among methadone patients found “6.5 times the rate of mortality than that expected in the population.”

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.

Also, keep in mind that retention rates for methadone and buprenorphine are not great. And, as noted earlier, methadone has higher retention rates.

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

Just to be sure that my position is understood. I’m not advocating interfering with people having access to maintenance.

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.”