Wednesday, September 7, 2011

Promises Offers a False Promise: Where “Belief” Trumps Science

Promises Malibu is one of the high-end programs frequented by Hollywood celebrities and other wealthy people that charges in the neighborhood of $55,000+ per month for “treatment” that includes things like “equine assisted therapy” and the “ropes course,” which is described as “…a fun, safe yet challenging personal growth and team building activity that our clients partake in.” Promises says it offers “… the most diverse, cutting edge, and non-traditional forms of therapy available in order to give our clients an individualized and well-rounded treatment experience.”

Unfortunately, they also offer treatment that causes relapse and kills people. The “Detoxification from Suboxone Maintenance Program” purports to offer a “clinically sound detox program” that “fills this gap in addiction treatment.” What is the rationale, the sound underpinning of this program? “At Promises we have always believed that drugs such as buprenorphine, Suboxone, and Subutex are best used for detox and stabilization, and that our clients are best served by helping them become completely free of them.” They believe that these drugs are best used for detox and the clients are best served by detox.

However, they evidently do not believe in the scientific method. There is not one single study that shows that withdrawal from maintenance medication improves outcomes. In fact, every study ever published concludes the exact opposite. In 2009, the United Nations World Health Organization published guidelines based on an international consensus that maintenance therapy with either methadone or buprenorphine produced far better outcomes than detoxification. Here is their summary of the available evidence: “Of the treatment options examined, opioid agonist maintenance treatment, combined with psychosocial assistance, was found to be the most effective. Oral methadone liquid and sublingual buprenorphine tablets are the medications most widely used for opioid agonist maintenance treatment. In the context of high-quality, supervised and well-organized treatment services, these medications interrupt the cycle of intoxication and withdrawal, greatly reducing heroin and other illicit opioid use, crime and the risk of death through overdose. Compared to detoxification or no treatment, methadone maintenance treatment (using mostly supervised administration of the liquid methadone formulation) significantly reduces opioid and other drug use, criminal activity, HIV risk behaviours and transmission, opioid overdose and all-cause mortality; it also helps to retain people in treatment. Compared to detoxification or no treatment, buprenorphine also significantly reduces drug use and improves retention.” Every single study or review of the data has concluded the same thing: opioid agonist therapy with methadone or buprenorphine saves lives, reduces drug use and crime and leads to improved overall outcomes, as compared with any “abstinence oriented” treatment.

But in the United States, “belief” trumps science when it comes to addiction. Treatment programs talk about their “philosophy” as though this were a matter of epistemology or ethics. It isn’t either. This is as cut and dried as it gets in modern medicine. The evidence for agonist therapy is much better than for stenting of coronary arteries, joint replacement, back surgery or most treatments for cancer. It is one of the most cost effective interventions in all of health care. About the only thing more cost effective is vaccination for childhood diseases. Yet we somehow are cowed by the “special knowledge” that “addiction experts” allege but that they can’t really share or explain the basis for. It’s time for the American public to demand that addiction treatment be based not on personal conviction, but on scientific evidence and professional scholarship.

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