Abstinence-oriented treatment has taken a beating in the media recently. There have been lots of assertions that medication maintenance approaches are THE evidence-based approaches and that abstinence-based approaches lack evidence and kill addictions. We know this isn’t true and have posted repeatedly on the subject.
Right on time, Drug and Alcohol Findingsreviews a recently published Cochrane report on buprenorphine vs. methadone maintenance:
Dosing levels were flexible in 11 studies which compared the two medications. Across these, the chances of a patient leaving treatment during study periods ranging from six weeks to a year was 17% lower on methadone. This means for example that if 60 out of 100 patients are retained on buprenorphine, had they instead been prescribed methadone, typically another 12 would have stayed in treatment. Results were similar and more consistent across the five double-blind studies in which neither patients nor clinicians were told which medication the patient was taking. Among the remaining six non-blinded studies, methadone’s retention advantage was not quite statistically significant and varied considerably between studies.
Across the eight flexible-dose studies which provided this data, numbers of urine tests indicative of continuing heroin use only slightly and non-significantly favoured buprenorphine. The same was true for the patients’ own accounts of their heroin use. There were also no significant differences in use of cocaine or benzodiazepines, though in both cases there was a slight advantage for methadone. Just two studies contributed to the analysis of criminal activity, cumulating to no significant difference between the medications.
In the fixed-dose studies which compared buprenorphine with methadone, retention was only significantly different (patients stayed longer on methadone) in the low-dose comparisons of less than 16mg of buprenorphine versus less than 40mg of methadone. In no dose range did one medication versus the other result in significantly fewer urine tests or self-reports from the patients indicative of heroin use.
Across the 11 studies which compared buprenorphine to a placebo , buprenorphine in whatever dose range retained patients better in treatment. However, only high-dose (at least 16mg per day) buprenorphine led to fewer urine tests indicative of continuing illegal heroin use.
This review looked only at retention on medication and reductions in drug use. So, the bar is set pretty low. So . . . here’s what we’ve learned from the evidence-base:
Retention: Buprenorphine achieved a retention rate of 60% with study periods of as brief as 6 weeks and no longer than 1 year. Common sense would suggest that, if 60% is the average, the one year retention rate is significantly lower than that.
Drug Use: Buprenorphine only reduced drug use at high doses–16mg or higher.
This is now familiar.
Researchers set the bar low and a drug therapy does not reach that bar. The solution is that the patient never stops taking the drug. The drug therapy still doesn’t reach the bar and the solution is higher doses of the drug.
First, with methadone. We shift from methadone detox to methadone maintenance. Then the evidence-base pushes higher doses.
Now, with buprenorphine. The evidence-base finds “near universal relapse” when using it as a detox tool and we’re pushed toward buprenorphine maintenance. Now, the evidence-base finds continued drug use and the solution is higher doses.
Here’s Drug and Alcohol Findings‘ summary of the comparison between buprenorphine and methadone:
. . . patients dependent on large doses of opiates may find it [buprenorphine] inadequate because there is a ceiling beyond which higher doses do not augment opiate-type effects. Patients who value the ‘wrapped in cotton wool’ feeling typical of heroin are likely to prefer methadone ; those who value a clearer head might prefer buprenorphine.
I guess a clear head is relative.
On life after medication-assisted treatment (The UK has been relying on maintenance for decades and is moving away from it because maintenance patients have not been successfully re-integrating into society.):
Patients aiming for a relatively rapid break from all opiate-type drugs might do best to opt for buprenorphine initially, or to switch to it after stabilising on methadone, but have to accept the risk that instead they will drop out and return to dependence on illegal drugs.
. . . buprenorphine’s ability to help patients take a half-step away from reliance on opiate-type effects and its greater ‘leavability’ could become valued more, while methadone’s ‘stickability’ is being seen not (or not only) as a strength, but a liability. However, buprenorphine’s leavability is itself a liability if it means (as in this British study ) that many more patients drop out and still only a small minority leave after successful detoxification.
The problem is that this isn’t what patients are looking for. They want their lives back. They want recovery. The evidence-base for these drugs is for reducing overdose, reducing drug use, reducing criminal activity and reducing disease transmission. They are not an evidence-based treatment for promoting recovery.
If what you want is an evidence-based treatment that’s associated with complete abstinence, low relapse rates and returning to employment, they exist and have a robust evidence-base. Health professionals and pilots have programs with outstanding outcomes. And, it doesn’t have to be expensive .
I’ll end with 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 the abolition of maintenance treatments.
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.”