Differences in outcomes between people receiving and not receiving opioid substitution therapies

From a recent study comparing various health and quality of life outcomes for methadone and buprenorphine patients with  addicts who are not in treatment [emphasis mine]:

Polysubstance use profiles exhibiting a broad range of substance use were generally at increased risk of negative drug-related outcomes, whether or not participants were receiving opioid substitution therapies (OST), including thrombosis among OST receivers, injecting with used needles among OST receivers and non-receivers, respectively and violent criminal offences among OST receivers and non-receivers, respectively. An important exception was non-fatal overdose which was related specifically to a class of people who inject drugs (PWID) who were not receiving OST and used morphine frequently.

It’s not an easy read, but here’s more from the discussion section of the article [emphasis mine]:

Our findings provide novel evidence of the patterns of drug use and drug-related outcomes between regular PWID receiving and not receiving OST. Strikingly, in both groups a class emerged exhibiting broad-ranging polysubstance use which was at the greatest risk for most of the negative outcomes. While we must interpret the results from any complex model with caution (in our case there are known difficulties in LCA with regard to deciding upon the ‘best’ class enumeration), our results reinforce the growing idea of broad-ranging substance use as the polysubstance use profile with particularly negative consequences for the individual and society [2]. From a clinical perspective, among individuals who inject drugs and use a broad range of substances, those receiving OST were not found to have better outcomes in our naturalistic and cross-sectional study, suggesting that alternative intervention strategies may need to be found. This is in keeping with meta-analytical findings showing that those with polysubstance use disorders were among the least responsive to treatment [23], while a recent review suggests that further research is needed to conclude as to whether it is more effective to treat multiple substance problems concurrently or sequentially [2].

Further, in considering these two broad-ranging polysubstance use profiles, those receiving OST had the highest odds of participating in all three types of criminal activity, including violent offences. Although reverse causation must be considered (i.e. criminal behaviour resulted in apprehension and enrolment in treatment), this high level of criminal involvement was found despite having received treatment for at least the 6 months prior to interview. Along with the fact that receiving OST in the full sample was not associated with reductions in violent offences and drug dealing, and associated with increased property offences, our findings are inconsistent with an earlier Norwegian study which found that OST was beneficial in reducing drug-related criminal activity if injecting persisted [10]. The reason for this inconsistency is hard to identify and, as the study design is similar to ours, is unlikely to be attributed to methodological differences. Instead, we that suggest the profile of OST users may differ between Australia and the Netherlands, with OST in the former context not related to decreases in crime if injecting persists. When interpreting this result it must be remembered that due to the sample eligibility requirements our findings are not related to individuals who receive OST and stop injecting.

They did find protection from non-fatal overdose.

A potential benefit of OST was found in relation to non-fatal overdose. Those not receiving OST had greater odds of experiencing a non-fatal overdose in the previous month, with this increase attributed to morphine users, who were 80% more likely to experience non-fatal overdose when compared with all of the other polysubstance use classes combined. Thus, broad-ranging polysubstance use does not seem to play a role in this outcome. Rather, the heavy use of a single prescription substance (i.e. morphine) was associated with an increased risk of non-fatal overdose, after adjusting for covariates including the advanced age in this class.

I also posted a few years ago on another study finding buprenorphine maintenance was not associated with reduced criminal activity.

When confronted with these kinds of findings, practitioners and researchers are left with an important question: Is the problem me and my treatment? Are we not up to the task? Or, is the problem these patients?

It should be no surprise that they go with the latter explanation. Their conclusions, and the other commentary in the journal, suggest that the problem is those darn injecting poly-substance users. There just isn’t much hope for them.