Introduction
Opioid Substitution Therapy has been a controversial topic. Somehow it is easier for the addiction recovery industry to accept medications such as Disulfiram with its aversive effect or acamprosate which does not carry the risk of approximating the state of alcohol intoxication and because studies have suggested that it is only effective in conjunction with psycho-social interventions. OST, on the other hand, uses opioid agonists or partial agonists that act in similar ways to the drugs of dependence, albeit without the same quality of high, and this, some have suggested, shifts the addiction from opioid dependence to another dependence and may be of more harm than good to the addict.
Methedone, the original medication of choice in OST, has been described as both saviour and devil by addiction professionals, lay counsellors and those recovering from or still suffering from addiction. More recently Buprenorphine has taken centre stage. At any rate, it has always been proposed that it is “Medication Assisted Treatment”, with treatment being some form of psycho-social intervention, while it is the medication that is the add-on in this process of recovery.
Because of this thinking OST has largely been used as a temporary means of managing the short-term issues of dependence i.e. detox. Recent research, however, has shown that rather than being a supplement to treatment, OST may be the treatment itself. Two recent studies both suggest that adjunctive counselling and/or CBT do nothing to improve outcomes. These are also consistent with previous studies, although more adamant (Fielin, Pantalon, & et al, 2006).
This research flies in the face of traditional “recovery” based thinking and there is now a debate between two seemingly opposing factions. It is “Recovery” versus “Treatment”, and as more and more addiction treatment professionals accept that addiction is a brain disease that can be treated by medication, and as medication for other addictive substances emerges, this topic is going to be more hotly contested. And there is a lot at stake: If addiction can be treated by a series of 15 minute General Practitioner office based interventions a lot of people will be out of a job, the rehab industry would shut down and there would be little need of 12-step fellowships. On the other hand the insurance companies would save millions while the pharmaceutical companies would make billions.
So what is this debate all about? Let’s start by looking at the two research papers I have mentioned above.
The Research
One study (Weiss, Potter, & et al, 2011) looked at over 600 prescription opioid dependent individuals who received buprenorphine in a 2-phase randomized control trial.
What the study concluded was:
· Addiction counselling made little or no difference to outcomes
· Tapering, even after 12 weeks resulted in poor outcomes
· Those who were stabilized on buprenorphine had considerably better outcomes
· Physician initiated office based treatment is possible
For the purposes of this article, what is important in these findings is that drug counselling made almost no difference. What should be noted, however, and what may be of importance, is that the majority of the patients in this study where employed, well educated, had short histories of opioid dependence and virtually no polysubstance use.
Although this study does not provide a complete description of the Opioid Dependence counselling they used, it sounds a lot like psycho-education and CBT: “Counsellors educated patients about addiction and recovery, recommended self-help groups, and emphasized lifestyle change. Using a skills-based format with interactive exercises and take-home assignments, ODC over a wider range of relapse prevention issues in greater depth than did Standard Medical Management, including coping with high-risk situations, managing emotions, and dealing with relationships.”
In early 2013 headlines proclaimed “CBT is not effective in treating heroin addiction” (or words to that effect) after the publication of a study by David Fielin and others at Yale University School of Medicine (Fiellin, Barry, & al, 2013).
This study “conducted a 24-week randomized clinical trial in 141 opioid-dependent patients in a primary care clinic.” One group received only physician management while getting their buprenorphine, while the other group received this plus CBT.
The conclusion: CBT added no benefit.
Why these findings are controversial is because it has always been assumed that psycho-social interventions form the core of addiction treatment and recovery from the addicted state. A Cochrane Review entitled “Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification” (Mato, Minozzi, Davoli, & Vecchi, 2011) concluded: “The review authors searched the medical literature and found evidence that providing a psychosocial treatment in addition to pharmacological detoxification treatment to adults who are dependent on heroin use is effective in facilitating opioid detoxification.” This seems to conflict with the findings of these other studies.
What research certainly does tell us more clearly is that Opioid Maintenance Therapy does keep patients engaged in therapy and keeps them abstinent longer (Mattick, Breen, Kimber, & Davoli, 2009) (Sees, et al., 2000) (Kleber, 2007) (Caldiero, Parran, CL, Piche, & B, 2006) (Donovan, Knox, Skytta, Bayney, & DiCenzo, 2012). There appears to be little research doubt that open-ended Maintenance Therapy is better than using OST as a means of detox.
So why the controversy?If one looks at the various discussions that take place between addiction professionals and those recovering from addiction on sites such as The Fix and LinkedIn, we can easily see that two camps have emerged.
I know that many will criticise the names I have given these two camps, they are not perfect, and I know that there are many who fit somewhere between the two, but for the purposes of this article I have chosen these names and I have defined them as such:
Those that believe that abstinence means that long-term OST is not an option, or is somehow second rate, and that there should always be the goal of medication-free recovery. They also believe that medication is an adjunct to other treatment modalities.
This camp says that indefinite OST is what the research is saying is effective, and they further believe that OST is the treatment in itself, and anything else is at best an adjunct, and often not necessary.
Until recently you could not go to Hazeldon and be on OST. Most of the Minnesota model based recovery industry is still firmly in the “recovery” camp. They are/were firmly abstinence based. In the world of celebrity and television the program “Celebrity Rehab with Dr Drew” has reinforced this school of thought: Dr Drew claims that methadone “takes your soul away”. To reinforce this view, here is an extract from an article from the Canadian press:
Harm reduction just keeps addicts enslaved
By Jon Ferry, The Province March 13, 2013
The UN Commission on Narcotic Drugs is meeting in Vienna this week to recommend measures to combat the world drug problem.
But in Vancouver, the war against illegal drugs appears to have been won already by those who favour "harm reduction," with its publicly funded crackpipe kits, safe-injection rooms and "free" heroin and methadone fixes.
This does little more than apply a Band-Aid — as opposed to abstinence-based treatment, which actually gets people off drugs but is frowned upon by the politically correct powers-that-be.
Here is another typically representative comment from a LinkedIn discussion in a closed Addiction Professionals group:
I guess I just find it a little disappointing that after 50 years of research and study, the best we've come up with for opioid addicts is a way to make them more successfully dependent on an opioid.
There are whole websites dedicated to the cause, and they are evangelical about the matter: check out the site called www.subsux.com. Filled with graphic descriptions and an alternative dictionary of expletives, the editor of the site says that:
If you want to read actual unedited experiences that aren't sponsored by the pharmaceutical companies or filled with suboxone promoting sub sucking zombies telling the "victim" that the reason their wd's are lasting so long is that they tapered wrong, or that it wasnt the sub but all the drugs they did prior to sub, or depression then you're in the right place.
On the other side of this camp are the likes of Dr Mark Willenbring, former director of Treatment and Recovery Research at the National Institutes of Alcohol Abuse and Alcoholism and now CEO of Altyr, who made the following comments in a discussion on the LinkedIn Addictions Professionals Group:
As for whether opioid medication is a black or white issue, it is. This is not one of those situations where some studies are positive, some negative, and only in the meta-analysis can you conclude whether something works. This is a situation where every quality study ever done comparing abstinence to maintenance shows a very powerful effect for medication. It is the primary treatment recommendation of the World Health Organization. Opioid agonist therapy is more effective than treatments for high cholesterol, diabetes, heart disease or arthritis.
What happened to requiring counseling along with Suboxone? We found out it didn't matter for most people, unless they had co-existing mental disorders. As I posted in my blog, it's not medication-assisted treatment, the medication is the treatment. And like it or don't but the relapse rate is >90% when people go off of it, or methadone, even after being on one of them for months (or years) and being given counseling of a quality far superior to anything available in the community. These are established facts, no matter how distasteful one might find them. Nasty little thing about scientific research is that it doesn't always reinforce what we already "know" to be The Truth. But that's what the scientific method is for.
And as professionals we are ethically bound to tell our patients what the evidence shows even if (or especially if) we wish the facts were different. As Bernard Russell once said: "When the facts change, I change my mind. What do you do, sir?"
And then from private correspondence with Dr Willenbring:
My own experience is that for many people with opioid addiction, agonist therapy is all they need. Others who have additional psychopathology need other services as well. It does need to be individualized. What I like about this finding, along with others, it that it disputes the prevailing notion that therapy or counseling is a required element of recovery, when it clearly is not. I think we cling to that belief mostly out of (unconscious) self interest.
And then again from the otherside:
I've sent plenty of addicts to OST/OMT programs but I don't like the idea of referring to a program with little or no treatment and no exit plan to speak of. This came to my attention recently through a friend who's trying to help his sponsee leave bupe maintenance after 3 years of otherwise productive recovery. It seems to be a pretty difficult process, which makes me think bupe isn't as easy to detox from as I had been told.
The other thing that concerns me: pretty soon we're going to have a million addicts on bupe OMT.
And in case you were wondering about my own beliefs, here is my response:
By no manner of speaking is long-term OST addiction, or keeping a person addicted. To equate dependence and addiction is also misguided. There are many amongst us who need long-term or even life-long OST and to deny them that is unethical. Research tells us that OST is the primary treatment in many cases. But as they say, one good personal anecdote destroys 10 years of double blind studies. No matter what our personal feelings, if we are addictions professionals, OST and harm reduction HAVE to be on the front page of the menu of treatment options, otherwise we are nothing more than quacks.
But does that mean that I am firmly in the treatment camp? Certainly not. I have a lot of worries about us seeing OST as a complete treatment by itself. I have criticised the Yale study in a previous article which can be found on my blog site: www.addictioncapetown.blogspot.com. Some of my thinking about long-term use has changed in the face of research, but essentially my criticisms of the research findings as reported and perceived still stand:
Most of my criticism of the Yale study can be extended to the Weiss study, and indeed most other studies that propose medication as the end in itself revolve around the following main issues:
· They measure the wrong thing
· They measure it over too short a time
· They exclude some significant populations
· They focus on CBT as the counselling approach with which to compare outcomes
· They ignore other aspects of recovery
They measure the wrong thing
What should we measure when it comes to recovery from addiction? If we regard abstinence as the measure of success, then certainly OST is successful. If we see heroin addiction as equalling heroin dependence, I think we are missing the root of addiction. Through various processes, and on many levels, those with an addictive disorder have developed a set of thinking patterns and behaviours which are often not compatible with the achievement of their life goals. The drug has a salience that exceeds mere physical dependence, there is a lot invested in the processes and relationships of the addicted state and to simply measure abstinence is not giving a clear picture. The Weiss research reports that there is little or no change in levels of criminal behaviour, for instance (Weiss, Potter, & et al, 2011).
We should be measuring quality of life as well, in my opinion.
Most studies, with a few notable exceptions, report on relatively short-term outcomes. Certainly the studies I have referred to in this article have focused on a maximum of 6 months after treatment initiation. We also know that in these studies if the patient discontinued use the relapse rate was >90%. My question is: Is long-term OST sustainable? We know that adherence to chronic medication is not good – about 50% (Brown & Bussell, 2011), so this does not bode well for continued sobriety.
The perception created by the Yale paper, especially evident in the interviews with the researchers and in the press, is that those suffering with opioid addiction can be cured with medication. What they fail to point out is that within the “addicted” group there are a large number of patients with comorbidity and those who clearly self-medicate. There is little doubt that these populations require further interventions, and if we start presuming that a simple office initiated medication based regimen will be sufficient for this population we are naive.
They focus on CBT as the counselling approach with which to compare outcomesI agree that CBT is a fair place to start when comparing various modalities of treatment for addictive disorders. CBT seems to be the recommended intervention, but then again I have similar criticisms of CBT studies as I do of the Yale study. Most studies focus on abstinence not quality of life and short periods of up to 12 months after treatment initiation. Most people seeking treatment have been users of their drugs or activities of choice for many years. The mean using years in the Yale study was 8.
CBT in addictions treatment focuses on the “here and now” and is essentially designed to bring about behaviour modification, prevent relapse and provide techniques to reduce cravings. It does this fairly well compared with other modalities in short-term comparisons, but there is little difference when compared with other modalities in longer term studies.
So, essentially, you are double-treating the same issue. No wonder CBT seems to add little value. Medications work better when it comes to short-term behaviour modification. But do they work better in the long-term? We will have to wait and see.
My criticisms of the Recovery Camp are:
· They place undue emphasis on 12-Step recovery
· They believe OST is not abstinence
· They tend to ignore the evidence
Both in the outpatient and inpatient settings, the recovery camp tend to place too much emphasis on 12-step programs. In-patient facilities often charge a fortune for what are essentially nothing more than a bunch of 12-step meetings in a draconian environment. Out-patient settings are much the same and often focus on confrontational styles of intervention as laid out in many 12-step facilitation manuals. In my mind, while 12-step programs are a fantastic and free resource and undoubtedly work for some, they have little place as a stand-alone treatment modality in the professional setting.
Along with 12-step recovery comes a number of other issues that are problematic in the professional addiction care setting, which I will not discuss here, but there is one major problem:
Abstinence is where it starts and ends in the recovery camp. You must abstain from all mind-altering drugs. Full stop. Some 12-step programs will not allow those on OST to hold service positions. The more radical ones say that taking an opioid for pain management is relapse. Just like the treatment camp, but in reverse, they see dependence as addiction.
To consider one of these camps as either definitive or irrelevant would be missing an opportunity to find a more complete and balanced approach to addiction care. And although I used him as an example of the “treatment” camp, Dr Willenbring also wrote this to me in our private correspondence:
And, BTW, I use both CBT and brief psychodynamic therapy myself, as well as supportive therapy.
Here in the USA, which is so dominated by 12-step ideology, it needs to be said again and again that not everyone has to go to AA the rest of their lives, and that 12-step counseling is not always needed. That may color my remarks. What I was trying to do in the blog was to counter the notion that 12-step rehab is the necessary and sufficient condition for recovery. In other countries where the 12-step influence isn't so strong, that might come across as too pharmacotherapy oriented, which I am not. I do more psychotherapy that most of my psychiatry colleagues here, where the norm is strictly psychopharmacology.
Perhaps the answer lies in knowing when and how to apply each of these modalities. I would agree with Avial Goodman (Goodman, 2001) who suggests that there are 4 phases of recovery from an addictive disorder:
1. Behaviour modification
2. Stabilisation
3. Character Healing (personally I prefer Capacity Building)
4. Self-Renewal
I would suggest that medication and short term “treatment” therapies like CBT (as applied in addiction treatment), are best suited to the first two phases while more “recovery” orientated interventions, such as life-skills, psychodynamic therapies, longer term CBT and peer support groups are more suitable for the final two phases.
So where does long-term OST fit in? Well, for some opioid addiction is a means of self-medicating a sluggish opioid system, and so they would need to compensate for this in order to feel “normal”. Perhaps this is pre-existing or as a result of extended substance abuse, either way the opioid absent system is not a comfortable one, and so they would find themselves vacillating between behaviour modification and short-term stabilisation. Surely for this individual it would be better for them to stay on indefinite OST so as to maximize their ability to engage in long term therapy?
Further, I would like to suggest that addiction takes place across three planes:
· Neurobiology – Neurochemistry
· Thought – Behaviour (short-term and long-term)
· Microsystem – Macrosystem
Each of these planes interact with and influence each other. So, for example, the neurobiology – Neurochemistry plane will have an effect on the other planes, to a greater or lesser degree. In the case of OST, this will have an almost immediate effect on the short-term Thought-Behaviour plane (the same plane where brief CBT therapies operate). These changes in behaviour can, in turn, influence the Systems plane. Positive feedback from the system will in turn influence the Thought-Behaviour plane and the Neurological plane and so on. In cases where there has not been long term abuse that has caused significant damage to the Thought-Behaviour plane or the Systems plane, I would suggest that OST may be enough to bring to life the process described here, and this will be enough for the capacity building and self-renewal mentioned above to take place.
For most opioid abusers, however, the Systems and long-term Thought-Behaviour planes have been so influenced by the Neurological Plane through the constant Neurochemical and behavioural influences of the opioids, that simple medication is not enough. I have spoken to many former substance users whose longing is not for the drug, but for the lifestyle. It is about the excitement and chaos and sense of control over one’s feelings and being able to self-regulate on a whim. It is the using friends, the sense of rebellion and the easy means of coping that have all become expected and easily attained by drug use that hold a far stronger allure than mere physical dependence. These aspects will seldom be addressed by OST.
And so, in conclusion, I would say: Treatment treats dependence, and helps one disrupt the addictive cycle, recovery treats addiction and helps build the capacity to engage in life without illicit substance use, and in many cases both are needed to in varying degrees to reach the goal of a meaningful existence.This all brings as back to the first principle of addiction treatment: “There is no one-size fits all solution.”
Works Cited
Brown, M., & Bussell, J. (2011). Medication Adherence: WHO Cares? Mayo Clinical Proceedings, 304-314.
Caldiero, R., Parran, T. J., CL, A., Piche, & B. (2006). Inpatient initiation of buprenorphine maintenance vs. detoxification: can retention of opioid-dependent patients in outpatient counseling be improved? American Journal of Addiction, 15(1):1-7.
Donovan, D., Knox, P., Skytta, J., Bayney, B., & DiCenzo, J. (2012). Buprenorphine from detox and beyond: preliminary evaluation of a pilot program to increase heroin dependent individuals' engagement in a full continuum of care. Journal of Substance Abuse Treatment, 44(4):426-432.
Fielin, M., Pantalon, M., & et al. (2006). Counseling plus Buprenorphine–Naloxone Maintenance Therapy for Opioid Dependence. The New England Journal of Medicine, 355:365-374.
Fiellin, D., Barry, D., & al, e. (2013). A Randomized Trial of Cognitive Behavioral Therapy in Primary Care-based Buprenorphine. The American Journal of Medicine, 126(1):74e11-74e17.
Goodman, A. (2001). What's in a Name? Terminology for Designating a Syndrome of Driven Sexual Behaviour. Sexual Addiction and Compulsivity, 8: 191-213.
Kleber, H. (2007). Pharmacologic treatments for opioid dependence: detoxification and maintenance options. Dialogues Clinical Neuroscience, 9(4): 455-470.
Mato, L., Minozzi, S., Davoli, M., & Vecchi, S. (2011). Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification. The Cochrane Collaboration, Wiley.
Mattick, R., Breen, C., Kimber, J., & Davoli, M. (2009). Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. The Cochrane Review.
Sees, K., Delucchi, K., Masson, C., Rosen, A., Clark, H., Robillard, H., et al. (2000). Methadone maintenance vs 180-day psychosocially enriched detoxification for treatment of opioid dependence: a randomized controlled trial. Journal of the American Medical Association, 283(10)1303-10.
Weiss, R., Potter, J., & et al. (2011). Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence: A 2-Phase Randomized Controlled Trial. Arch Gen Psychiatry, 68: 2011-2121.
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