More on treatment for opioid addiction

Here is the text of a letter I sent today to a reporter at Minnesota Public Radio. They had previously run a program that was neither accurate nor complete.

MW


Dear Kerri,

I'm writing about your recent program on painkiller addiction. Unfortunately, I was not able to join the call, but became aware of it after the fact. I appreciate your attention to this problem, as it is particularly affecting young people.

I have been an addiction psychiatrist for over 30 years, and I have treated something like 1500 opioid addicts including about 30 in my current practice. In addition, I am an expert in treating highly complex pain patients who are using opioids. I used to run the addiction program at the VAMC in Minnepolis, which included a methadone maintenance clinic and eventually Suboxone treatment. From 2004 to 2009 I was Director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism. (Not to brag, but I wanted to give you some sense of bona fides.)

One area where addiction treatment in the US really lags is in making scientifically based treatment available to people who need it, or even informing them of the evidence and their options. This is no where more true than opioid addiction. There are now multiple well done randomized controlled trials that have unequivocally and without exception found that for established (>1 year) opioid addiction, the only proven effective treatment is long-term opioid maintenance with either methadone or Suboxone. The most recent study, reported last spring at the American Psychiatric Association, focused on prescription opioid addicts, not heroin addicts. (Most previous research has been on heroin addicts.) This large and very well done study found that even after 9 months of Suboxone maintenance, along with enhanced psychosocial (behavioral) treatment of a quality far in excess of that available in the community, the relapse rate after tapering off of Suboxone was 95%. A recent naturalistic study in the UK followed opioid addicts who sought treatment. Those choosing abstinence had twice the mortality rate in the following year as compared to maintenance. These are only two of the most recent studies. There are dozens more. Among experts on opioid dependence, there is no controversy about this. (To anticipate a possible counterargument, there is evidence that an injectible drug that blocks the effects of opioids may be effective during the period when someone is on probation under the condition of agreement. However it is also true that almost all relapse as soon as they are off probation.)

Here's the problem. Due to devotion to 12-step concepts of addiction (which are not scientifically grounded), most treatment programs in the US fail to inform people of this evidence, let alone offer to provide it. Opioid dependence continues to be treated with an abstinence based approach grounded in the 12 steps. When the predictable relapse occurs, patients and families are told that the individual needs more abstinence-based rehab. The patient is held responsible for the failure of the treatment. There is an implication that if a person only accepts the program whole cloth and practices it religiously, then success is assured. In fact, it is the treatment that is ineffective, not the patient. Addiction treatment is the only place in modern health care where providers are not held responsible to give full informed consent to their patients, or for the success of their treatment. I currently have several patients who have been through multiple abstinence programs at a cost of tens of thousands of dollars each, who are now doing well on maintenance treatment.

This is not merely about infighting among the experts. Active opioid dependence has a high fatality rate; in one study 50% of the sample died between the mid-twenties and mid-fifties! And in the UK study, there was a mortality difference detectable after only one year. In addition, insurance companies and families spend millions of dollars on treatment clearly demonstrated to be ineffective, as much as $30-60,000 per month for residential treatment. Maintenance treatment, on the other hand is not only much more effective, it is much cheaper, on the order of a few hundred dollars per month. If we use $300 has an average maintenance cost, then one month for one patient in a residential program that cost $30,000 would buy actually effective maintenance treatment for 8 patients for a whole year! And that doesn't factor in the increased health care, criminal justice costs and loss of productivity that occurs with the higher relapse rate for abstinence based treatment. One study estimated the cost of maintenance treatment yielded savings more than 7 times a much.

I apologize for the long email, but I strongly feel that the public needs to have this information available to them. After being involved in research for over thirty years, I decided when I left NIH that the research didn't matter if there wasn't a vehicle for making it available to the people who are suffering with the disorder. So I am now devoted full time to transforming the treatment system into one that is based on science, professionalism, and cost-effectiveness and that is dedicated to offering consumers choice.

Thank you for reading this (if you get this far before pressing Delete). Of course references are available on request. I have had a lot of media experience and I have appeared on Mid-Morning before I went to Washington (I'm back in this area now.) I would be more than happy to participate in a program that presented a more balanced view. I could possibly suggest a patient or two who might be willing to talk about this on air as well.

Warm regards,
Mark