THE FALSE PROMISE OF MEDICATION-ASSISTED TREATMENT (MAT) FOR THE OPIOID CRISIS
By Clark Miller
Published July 27, 2018
Updated April 2, 2021
The substitute opioid buprenorphine in the forms of Subutex or Suboxone along with methadone used in Medication Assisted Treatment (MAT) has been in use worldwide for more than five decades. Perhaps the most direct and powerful evaluation of the potential effectiveness and benefit from MAT and most commonly 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, dramatically and lethally over recent years, instead of been moderated, over those decades of increasing provision of the medical fix?
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?
Those and other important questions for Americans increasingly trapped in lethal substance use epidemics will be examined and answered here, grounded in research and critical analysis of relevant evidence, not by accepting at face value and repeating the assurances and fabrications of the medical industries, health experts, and cooperate media generating those epidemics.
As explained and grounded in evidence and research in upcoming posts here, there are important reasons explaining why attempts by MAT proponents to interpret research findings to support MAT are selectively limited in use of outcome measures (to measures of overdose deaths, a measure confounded almost since the beginning of use of substitute opioids by the effects of use of the OD-reversing drug naloxone) – just as in the criminally incompetent and negligent fabrication of “evidence” to support indiscriminate, runaway prescription of opioids that created the opioid epidemic, there simply does not and never has existed meaningful evidence to support benefit, as opposed to harm.
For more detailed and 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.
In a rush to respond to the opioid crisis they created, 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 increasingly 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 promised to provide the assisted part of Medication-Assisted Treatment, assisting by creating conditions for motivated patients to 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 and correctional settings and increasingly in ERs, 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 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.
It seems important at this point for a 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
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.
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 2014 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 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.
That incudes understanding, consideration of, and ethical accounting for confounding factors that can qualify or invalidate research conclusions related to MAT, as discussed here.
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.