Medication-Assisted Treatment (MAT), using man-made opioids like Suboxone prescribed in medical settings to manage withdrawal sickness and risks of street drug use, is widely promoted and accepted as The Fix for the opioid crisis, but the research evidence is at best mixed and unclear, recent studies pointing to overall treatment failure and with continuing drug abuse; meanwhile the provided “Treatment” part (counseling and behavioral therapies) of MAT are traditional, “rehab”-type approaches that have never been effective.
In the rush to respond, manage the harm, and attempt to re-establish the appearance of competence and effectiveness in management of chronic pain, opioid use and related risks, the managed healthcare/medical industry has invested in a type of harm reduction strategy rebranded “Medication Assisted-Treatment”. In MAT the manufactured, prescription opioids methadone or buprenorphine (brand names Subutex, Suboxone) are dispensed and intended to provide the assisted part of Medication-Assisted Treatment, assisting by creating conditions for patients to basically feel and function better, in order to effectively access and benefit from the “treatment” part = effective (“evidence-based”) behavioral health therapies (the subject of multiple Upcoming Posts).
In medical settings opioid users are started on courses of the drugs, which provide a reduced level of the euphoric and sedative effect of opioids like heroin and at least relief from the highly distressing withdrawal symptoms – in intent and in theory. In theory, and in some clinical trials under non-natural conditions, but not reliably in practice, those effects minimize risks, stresses, and problems functioning in life related to use of illegal, “street” opioids and other drugs, promoting effective use of the treatment part of MAT. In the real world, under realistic community program conditions, things are different, and research results are disconfirming the idea that Suboxone and MAT are beneficial as currently designed and provided.
That focused and seemingly universal confidence in and reliance on harm reduction and MAT is embraced by the popular media and is managed in medical settings under medical, versus evidence-based behavioral treatment models, driven by the fictional and invalidated model of problem opioid use and substance use in general as a disease or medical condition. Predicting continued harm, MAT as currently implemented is driven by factors other than research and practices supported as effective by research for the actual treatment part of Medication-Assisted Treatment, because (Companion Post in SCIENCE – Doxa Deconstructed: Another Medical Fix not Supported by Evidence – Suboxone for the Opioid Crisis), 1) research evidence for effectiveness of those presumed medication-based benefits is at best mixed, with recent studies showing overall treatment failure and 2) the Treatment part of MAT, (the behavioral health therapies required to address the compulsive drug use) currently consists of traditional treatments, or “treatment as usual” (TAU), established by decades of research to provide no benefit or harm (Upcoming Post: Why Addiction Treatment Doesn’t Work).
Summary: When buprenorphine (Subutex, Suboxone) substitution works, it can effectively provide a period of improved mood, thinking, and functioning in life that supports effective participation in the actual treatment part of MAT (evidence-based talk therapies for the conditions and stresses driving compulsive substance use, a focus of multiple Upcoming Posts) by motivated patients, with predicted benefit.
When it fails to support patient engagement in effective treatment and change, as it generally does, MAT distracts resources and attention from critically needed, fundamental changes to substance use treatment models and methods, from critically needed reformation of the conceptualization of “addiction” itself.
It seems important at this point to have a critical look and critical discourse about the effectiveness of MAT, because it’s looking a lot like the Opioid Crisis and how we got there:
Medical Industry on the MAT response to the opioid crisis – But Look, we’re taking care of this! Okay, never mind the treatment part for an entirely behavioral, psychosocial problem, for a compulsive behavior driven by inner and outside sources of stress, we’re doing something, in medical clinics, with medicines! Always a good idea, right?
Sound familiar? Like what got us to the Opioid Crisis, now with prediction of 500,000 deaths over the next decade? It should sound familiar, needs to be recognized as familiar, as MO of the Medical Industry – But Look. Okay, never mind the indicated treatment part for an entirely behavioral, psychogenic (generated by mental and emotional states) problem, we’re doing something, in medical clinics, with medicine! We got this – prescribing opioid pain medications for chronic pain an entirely psychogenic, non-biomedical problem. What could go wrong?
Just in case something could go wrong with a medically-managed fix for an entirely non-medical problem, let’s take a look at the research and evidence, described and discussed in detail in the companion post in SCIENCE.
Popular media have followed along with the orthodox, establishment reinforcement and promotion of medical fixes for the medically-generated opioid crisis, citing reduced overdose deaths due to illicit opioid misuse as definitive and sufficient evidence and support for effectiveness of MAT and Suboxone as the fix for the epidemic. Numerous print and online news sources are running feature articles and series on the crisis, like at Vox where the appearance of reduced heroin overdose deaths with increased use of “anti-addiction” opioids like subutex in France in the 1980s and 1990s is asserted as establishing buprenorphine-based MAT as both effective and a form of “treatment”, a fix for the opioid problem. As portrayed by popular addiction writer German Lopez at Vox: “France had a big heroin epidemic in the 1980s and ’90s. Here’s how the country fixed it.”
Similarly, addiction writer Maia Szalavitz recently cited a 2017 retrospective (“looking back” at existing studies) cohort (= following an experimental group of subjects over time) study of patients provided methadone or buprenorphine for problem opioid use, interpreting and concluding that significant increases in overdose deaths for patients no longer retained in treatment determine that MAT is a first line or sole treatment approach to problem opioid use and the opioid epidemic, advocating for extended or life-long use.
These lines of evidence and research and their use to generate confident conclusions about effective treatment for a public health crisis are important to examine and analyze, because conclusions of effectiveness are not supported by the research. For that, see this week’s companion post.
That critical examination of the evidence currently cited in popular media to support effectiveness for MAT and Suboxone approaches can be summarized:
1) Claims of significant benefit due to prescribed substitute opioids like buprenorphine for problem opioid use or in reducing overdose deaths and the research marshalled for those claims have not distinguished between benefit possibly due to the strategy of MAT (or “opioid substitution treatments” OST) versus likely decreases in lethal overdoses (distinct from nonfatal overdoses and high risk or problem drug use) due to another strategy increasingly used concurrently and in conjunction with the opioid drugs: development of and increase in availability and access to emergency overdose antidote Naloxone kits, with training and dissemination efforts aimed at professional and natural supports for opioid users integrated into MAT services and associated community supports.
That effect confuses things and prevents clear interpretation of results – do overdose deaths decrease because buprenorphine use has therapeutic factors, changing users’ lives in lasting, positive and protective ways that decrease risk of drug abuse and overdose? Or are users, while in buprenorphine programs, more connected to healthy, functional social environments, and socially isolating less – as opposed to “street”, or drug culture life – so that overdoses are more likely to be responded to effectively, preventing death?
2) In the French experience, increasingly widespread use of overdose death-preventing Naloxone kits by emergency medical professionals coincided with the period over which buprenorphine was increasingly prescribed and OD deaths decreased. More recently, French addiction professionals report continued serious problems in France with heroin, other opioids, overdose deaths, abuse of buprenorphine with heroin, and additional diversion (misuse) problems with buprenorphine. Heroin- and methadone-related overdose deaths increased over the most recent period reported, 2006 – 2009.
Those 2014 reports stand in marked contrast to American popular media accounts trumpeting that France fixed its heroin problem with buprenorphine.
3) In the analysis of cohort studies cited by Maia Szalavitz, neither problems with drug use by participants while in the methadone/suboxone programs, nor retention rates (how many subjects actually stayed in the program?) are reported, the study authors noting this as one of several confounding effects limiting confident conclusions. Clearly, any benefit in reduced overdose deaths – whether due to MAT as a strategy and benefit, or to associated increase in availability of emergency Naloxone kits – would disappear or likely diminish for individuals leaving the programs and becoming enmeshed in illegal drug use and culture. With retention rates typically low to very low in Suboxone trials (trending toward zero in this study, – see the data and trends reproduced and discussed here) conclusions about significant lasting benefits from Suboxone and MAT are premature.
Clearly, we need meaningful ways to measure whether Suboxone and MAT are helping beyond simply looking at overdose deaths.
Just as important, we need careful analysis of the research and quality of the research and conclusions fueling the rush to use MAT as a fix for the opioid crisis, to avoid completely missing what the research and evidence is telling us – to learn from and avoid repeating predictable harms like those generating the opioid crisis.
To highlight some confounding factors that can qualify or invalidate research conclusions related to MAT, discussed in detail in the companion post on the site page SCIENCE:
- It is not legitimate to “cherry pick” published studies that seem to provide positive outcomes and ignore others with poor outcomes (that’s how the pharmaceutical companies falsely inflated effectiveness of antidepressants).
- It is not legitimate to rely on “Meta Analyses” type studies – published collections of previously published studies in which conclusions are drawn based on “consensus” or tendencies of those studies to support a type of outcome, like benefits versus no benefit, because in research the devil is always in the details – a collection of studies with similar conclusions and with flaws that prevent or invalidate interpretation of results is no more confident and powerful as evidence than a single inadequate study.
- As explained, some of numerous factors that can prevent or alter interpretation of research results include 1) Were the apparent results lasting? 2) can results be applied to real community treatment situations? And 3) are positive outcomes undermined by factors not measure in the study, like subjects turning to other drugs of abuse?
The confounding, inconclusive nature of evaluation of effectiveness of MAT based entirely on overdose deaths makes it necessary and important to look at additional measures of potential benefit or harm, like what proportion of subjects actually stay in the program – some studies demonstrating treatment failure by that measure: for example less than 5% treatment retention/success rate; and with MAT for prescription opioid abuse, 91% failure over a 12-week trial).In an important study that overcomes a number of the discussed factors that can invalidate conclusions about research results, discussed in detail in the companion post, results also point to treatment failure: retention of patients at 6 months in the programs at 20% and 30% and clearly trending downward, with between 11% and 45% of those remaining abusing other drugs.
Consider: buprenorphine (Subutex, Suboxone) used in MAT has been in use worldwide for more than three decades. Perhaps the most direct and powerful evaluation of the potential effectiveness and benefit from Suboxone for the opioid crisis would be simply to pose the questions:
1) If effective, why has problem use of illicit and prescription opioids worsened, instead of been moderated, over those decades?
2) If effective, why must proponents of MAT resort to citing what appear to be positive results on only one measure – overdose deaths – unable to provide a body of research pointing to success and benefit by other measures of reduced risks, problems, and harm?
Evidence for the universally accepted medical fix for the medically-generated opioid crisis, Medication-Assisted Treatment, is at best inconclusive, with multiple studies pointing to treatment failure and MAT as a currently unvalidated approach.
More fundamentally problematic, the over-focus on medically managed programs prescribing substitute opioids for the crisis appears to have resulted in the actual treatment part of MAT regressing to traditional “addiction treatment”, or treatment as usual (TAU), approaches that have never been evidenced as effective.
For more detailed research- and evidence-based analysis of effectiveness of MAT, link to the companion post – Doxa Deconstructed: Another Medical Fix not Supported by Evidence – Suboxone for the Opioid Crisis.
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UPDATE: See new companion post – In a California county hard-hit by opioid abuse, reduced death rate points to OD reversal drug naloxone, not opioid substitute Suboxone