Thursday, July 11, 2013

Is Maintenance the Best Therapy for Opioid Addiction?

Ian McLoone
6:30 PM (4 hours ago)
to me
I have been having some heated discussions lately about maintenance and the science around it. A lot of people say, "well reduced drug use is great, but what about quality of life?" For example, the studies comparing buprenorphine with and without counseling - there's no difference in outcomes, but those outcomes don't measure QoL. I did some research, and most of the studies I saw found improvements, but in the case of methadone, the improvements all occurred in the first 30days of Tx. Just wondering what you say about this perceived lack of QoL in the literature. 

Mark Willenbring 
10:57 PM (3 minutes ago)
to Ian
QOL measurement is a conundrum, very difficult to measure, since it's a perception, an interpretation, and doesn't correlate well with more objective measures of function or discomfort. 

I think their argument is simply a defensive one. The counterargument is that many more people who are treated with abstinence-based therapies relapse and die. Dozens of studies, internationally. What kind of QOL do dead people have?

The fact is, the ball is in their court: if they can prove that overall QOL is better (as well as survival) with abstinence-based treatment, terrific. If not, shut the heck up. If you reject a scientific finding on ideological grounds, say so. It's fine to assert: "Yes, more people use fewer drugs and fewer die if they take medication, but they aren't "really sober", they haven't "spiritually grown. Therefore, the goods of less drug use, more remission and fewer deaths are outweighed by a moral argument that their recovery is false. It is better to die than to take medication, because maintenance is not morally acceptable." That's a potentially valid position if you agree with their assumptions, which I obviously do not.

But don't argue that the findings aren't what they are because you don't like them. More people recover using medications, fewer people have legal, job, medical or social problems, and fewer people die with medication. These are established facts that cannot realistically be challenged, other than by rejecting current scientific methods and a broad international consensus of researchers and senior clinicians, not to mention the World Health Organization, the National Institute on Drug Abuse, the VA and DOD, and the CDC. I think the burden on the other side is formidable.

As Bernard Russell said, "When the facts change, I change my mind. What do you do, sir?"



  1. Well stated. Often I heard the argument that treating people with opiate replacement therapy is "dangerous" because they might overdose or die. This always entertained me. It occurs to me that you might more easily do that while using illicit opiates. Of course, there are all of this risks of needle use, obtaining money to buy drugs, imprisonment, etc, that can accompany illicit drug use. Illicit substance use seems far more dangerous to me than maintenance therapy.

    The same provider who described the dangerousness of maintenance also "explained to me" that people who were still drinking and possibly in detox were too dangerous to treat in addiction treatment, go figure.

    Oh, I almost forgot another pearl of wisdom he shared - Naltrexone and Disulfiram are "crutches" that undermine recovery. This guy was a young psychiatrist and that made me sad. It means we have to wait a really long time for he and his stupid ideas to die off.

    Thanks for the post,

    1. One has to wonder how this newly minted psychiatrist acquired such a grotesquely punitive attitude towards persons trying to recover from alcoholism. If he is in recovery, this kind of rigid dogmatic 'fundamentalism' does show up among AA members, but seems much less likely to be harbored by anyone who's completed a psychiatric residency. Perhaps he simply needs therapy to address his alcoholic mommy or daddy issues.

      Mark Edmund Rose, MA
      Licensed Psychologist

  2. Most heroin addicts I have met who have had exposure to opiod-replacement therapy (suboxone, methadone) tell me of a vast difference in perspective that they, the actual drug addicts, and the doctors who prescribe them drugs and offer therapies, have. Most notably, they speak to the highly abuseable nature of any current licit opiod that is is designed to keep them alive and off illicit drugs. They describe their addiction as staying very much alive and hungry for stronger opiates as a result of this form of 'therapy'. Do you think that there can be such a large difference in perspective between scientists and addicts? It seems that non-addict scientists, researchers, and medical doctors are not realizing that what they offer is no solution at all in the eyes of most users. Whose view matters more, those who are in the business of getting paid to do research in the field, those who practice in the field by prescribing these drugs or the addicts themselves whose lives are at risk? I think it might be wise to consider the opinions of the very people you are trying to help and not merely the non-addicted,scientific professionals.

    1. Without knowing anything of the basis for your contact with the heroin addicts you mention, I'm guessing the context of your encounters with the folks you mention is through a 12-step program like NA or AA, or as a treatment provider of chemical dependency services. Either way, you are only interacting with those for whom methadone or buprenorpine did not work. People who have achieved stabilization and success on methadone or BPN don't show up to seek chemical dependency services or attend AA or NA (although this will hopefully change). Remember, we are talking about a class of drugs where every post-treatment relapse is potentially fatal, and all too many are.

    2. The reply to this comment makes an excellent point - those who tend to define maintenance as an equal-to-or-worse-than alternative to heroin or other opioids are probably not good candidates for maintenance medication - and the medications aren't necessarily for everybody. However, buprenorphine with its low effect ceiling and partial-agonist properties, and methadone with its relatively low euphoric effect are generally not abused by folks with a tolerance for opioids because they just don't feel good compared to oxycodone or heroin. Not to mention, at a therapeutic dose, virtually no sedation or noticeable effect can be felt.
      Ultimately, for the majority of patients, these meds provide a "freedom" from an old destructive way of life; a freedom from the obsession of use. The very nature of maintenance medications is that the addiction goes away. Sure, a physiological dependence is created - just as with antidepressants, insulin, and a host of other medications. The important difference is that the compulsive behavior, excessive time spent obtaining and using, the social and occupational problems, and the significant impairment or distress are all absent - the true hallmarks of addiction.
      I agree with you that the voice and opinion of the patients themselves is paramount. If a person decides they don't want to use a maintenance med then they should not, and they should receive the best care possible. However, they should also know that their likelihood of relapse if substantially greater, and the risks relapse carries with it includes death. I disagree, however, that these medications are being pushed and propagated without the consent of the patients - the simple fact is that countless people have regained their lives thanks to the help of meds like these. Otherwise, organizations like NAMA would not exist:

  3. Dr. Willenbring,

    Would you agree that a person in recovery should have a solid relapse prevention plan in place regardless of the recovery path they choose. For example a person could choose abstinence-based recovery (AA/NA, CBT, counseling, etc.), Medication Management, or a combination of those, in whatever multitude of variations. Isn't it still imperative that they stay away from their former lifestyle as much as possible?

    -Stay away from the places you obtained your drug of choice?
    -Stay away from the places you used your drug of choice?
    -Stay away from the people that provided your drug of choice?
    -Stay away from the people you used with?

    What are your thoughts regarding these and other common relapse prevention measures with regard any treatment/recovery option available?


Comments are welcome.