Deconstructed 1. Media Failure Drives America’s Worsening Substance Use Epidemics

by Clark Miller

April 22, 2019

In the face of consistent, mounting evidence invalidating the constructed fabrication of a clinical and research base justifying use of substitute opioids to address America’s lethal epidemic, America’s medical, media and public institutions – the same coalition that constructed public heath disinformation to generate the opioid crisis – is doubling down on deception and protection of their control of cultural capital and public health resources.

As unflinchingly documented by Sam Quinones in Dreamland, the role of American media and research institutions in that unchecked promotion of runaway use of addictive opioids for the non-medical condition of common chronic pain, against all lines of relevant longstanding evidence, was to abdicate any investigative or watchdog function, instead to popularize the fabrications generated by pharmaceutical, medical, and insurance vested interests.

Dreamland cover 2

The role of uncritical popularization is retained by media, as decades long lethal trends for not only opioids, but alcohol, methamphetamine, other drugs continues to worsen despite $billions of dollars and decades invested in an invalidated disease model and medical approaches for the non-medical condition of compulsive use of substances.

It may be time to look and think more critically, to begin a critical discourse about these cultural and public health trends, continuing with a series of posts – “Deconstructed”.

Like many national and regional media outlets the online source Vox has run a series of features on the opioid crisis and related issues, many by writer German Lopez.

Lopez is the same popularizing writer claiming that essentially uncontrolled prescribing by any medical provider of substitute opioids (like buprenorphine and methadone) was the means by which France “fixed” its opioid problem based on the association in time of rapid expansion of medical dispensing of those opioids and significant reductions in opioid-related overdose deaths.
With competent analysis of those bodies of research and reports, it’s been made clear here at A Critical Discourse, was clear from the start, that those conclusions have been entirely unwarranted and it turns out false and dangerous.

In France,

where the world’s least restrictive and most intensive “revolutionary” substitute opioid (buprenorphine and methadone) medical dispensing experiment has been underway for decades, among other serious problems, opioid-related overdose deaths have trended upward over the most recent reporting period

French OD death trends 2006-2013

the apparent surge upward again in 2013, interestingly, appearing to follow introduction of Suboxone (bupe plus antagonist naloxone) to longstanding use of Subutex (pure opioid partial agonist buprenorphine).

Medically-disbursed buprenorphine in France seems to serve largely to supply, by diversion, street use of bupe in France and in other countries.

A primary, and telling, outcome of the French decades-long experiment – implemented on the belief that the world’s most developed OST campaign would provide the benefit, at least, of reducing high-risk opioid use – is the recent (2017) finding that France is 5th highest among 20 European nations in high risk opioid use –

France high-risk opioid use

Vox and its writers have remained undeterred in their popularization of the U.S. medical and pharmaceutical industry collaboration to promote the unvalidated use of medication assisted treatment (MAT), more specifically and also known as opioid agonist therapy (OAT) or opioid substitution treatment (OST)

The standard claim is made here that there is research proving that OST reduces mortality by 50 percent or more – “Studies show that the medications reduce the all-cause mortality rate among opioid addiction patients by half or more and do a far better job of keeping people in treatment than non-medication approaches.”

This is the study, or the type of study, cited repeatedly and used by popularizers of the medical MAT/OST response to the opioid crisis to claim benefit from buprenorphine/methadone harm reduction based on claims for the provision of those substitute opioids reducing overdose mortality. That’s worth looking at in some detail.

It’s worth noting that the studies – reviewed and summarized as a “meta analyses” of studies – are not controlled studies, instead longitudinal or cohort studies, with unavoidable confounding factors requiring critical analysis, replication and validation.

As noted by the authors:
“These findings are potentially important, but further research must be conducted to properly account for potential confounding and selection bias in comparisons of mortality risk between opioid substitution treatments, as well as throughout periods in and out of each treatment.”

So, it seems crucial

in order to protect vulnerable Americans from the type of lethal medical misinformation that, for example, created an opioid crisis, to consider the most important and elementary aspects of experimental design and interpretation that are critical to preventing misinformation.

The 19 studies in this meta-analysis included 16 in which prescribers provided methadone and 3 buprenorphine.

Patients accessing OST may be motivated to participate extrinsically (required for example, by a criminal justice court order or by child protective services) or intrinsically – choosing to access the services as driven by their desire to make changes in their lives related to problem, compulsive use of opioids.

For each type of patient, there are confounding factors tied to involvement in OST that would predict reduced mortality during the period of involvement and higher risk of mortality after that duration separately and independently of any presumed benefit from use of the substitute opioids.

This and similar studies cited as evidence of OST reducing opioid-related overdose deaths provides evidence of an association between reduced mortality while subjects are engaged in OST services and exposed to any associated protective factors, compared to the period after leaving those services and associated factors. The study noted the likely effects of “confounders” – of factors other than presumed effects of subject use of substitute buprenorphine or methadone – and did not provide evidence justifying attribution of decreased mortality to use of substitute opioids versus those other factors.

The least likely factor to account for the results is the presumed benefit in use of the substitute opioids buprenorphine and methadone resulting in decreased high-risk use of opioids or other drugs.
We know that because:

– There is no body of evidence to support reduced high-risk opioid use due to the presumed effects of substitution with buprenorphine or methadone – by reducing urges to abuse drugs while in OST or by fostering psychological and psychosocial change that reduces risk and compulsion to use.

– Instead, directly and clearly, provision of naloxone accounts for any and all apparent moderation of lethal overdoses in local programs and nationally, while high-risk use (as measured by incidence of injection-related infectious disease and by non-lethal opioid overdose) is not evidenced as benefitting from OST.

– Instead, patients in buprenorphine and methadone services abuse other opioids and other drugs of abuse at high rates.

 

Let’s take a look.

Methadone clinics

In Dreamland, Sam Quinones’ devastatingly unflinching indictment of American institutions and trusted medical and media authorities complicit in the lies generating the opioid crisis, methadone clinics are described as playing a crucial role in the wildly successful expansion of cheap, potent black tar heroin from Mexico into the U.S. – up the West Coast, into midwestern cities and everywhere in between – because those clinics are hubs for trade and use of illicit and licit drugs of abuse (p 64) –

Camping out in front of the town’s methadone clinic, he gave away samples of his dope and soon had a client list of desperate junkies avid for the black tar they’d never seen before.

. . .

They met at the town’s methadone clinic off Bryden Road the next morning. The clinic was a hive of illegal dope trading. Almost anything a user wanted was for sale. He gave Chuckie a few free samples and his beeper number.

That afternoon, Chuckie called.

“That’s some killer stuff you got,” he said. “I gotta whole buncha people want some of that.”

And in Indianapolis and Columbus, Ohio (pp 143-144) –

Methadone clinics gave Xalisco Boys the footholds in the first western U.S. cities as they expanded beyond the San Fernando Valley in the early 1990s. Every new cell learned to find the methadone clinic and give away free samples to the addicts.

One Xalisco Boy in Portland told authorities of a training that his cell put new drivers through. They were taught, he said, to lurk near methadone clinics, spot an addict, and follow him. Then they’d tap him on the shoulder and ask directions to someplace. Then they’d then spit out a few balloons [packaged black tar heroin]. Along with the balloons, they’d give the addict a piece of paper with a phone number on it.

“Call us if we can help you out.”

The value of each Xalisco heroin tiendita was in its list of customers. “This is how they would build and maintain it,” said Steve Mygrant, a Portland-area prosecutor. “It was an ongoing recruiting practice, in the same way a corporate business would identify customers.

The signs and reports everywhere, of what should be obvious, signs of why bupe seemed, at least on a superficial and unexamined level, to make sense as a safer alternative to methadone. Methadone, highly regulated and dispensed in clinics, in Appalachia the gathering places for illicit trade and use of opioids and other drugs.

From Beth Macy’s Dopesick (pp 215, 218) –

“I’m walking around the methadone clinic parking lot for two hours with a four-day-old baby,” Patricia said. “And it was loaded with addicts. It was a place where Tess’s circle of addicts would become even bigger than it already was.”

. . .

As early as 1963, progressive researchers conceded that designing the perfect cure for addiction wasn’t scientifically possible, and that maintenance drugs would not “solve the addiction problem overnight,” considering the trenchant complexities of international drug trafficking and the psychosocial pain that for millennia has prompted many humans to crave the relief of drugs.

America’s opioid crisis has proven those progressive researchers wrong – it’s not that maintenance drugs could not “solve the addiction problem overnight”, it’s that those drugs do not constitute treatment of any sort for “addiction” and instead, from longstanding and mounting evidence, are contributing to worsening epidemics.

Signs that are confirmed by research, like results reported in this study with high external validity, observations and data from patients in natural community treatment settings providing methadone and demonstrating

1) low retention rates, trending downward at 6 months and

2) high incidence of abuse of additional drugs including opioids

The top line is for methadone, with retention (patients staying in the program to utilize the “treatment” and associated supports to reduce high risk opioid use) at less than 50 percent at 180 days and clearly, as for Subutex and Suboxone, trending downward.

Substances abused (detected in urine screens) for methadone users included:

Other opioids – 17 percent of the 48 percent methadone participants remaining at 180 days (heroin or oxycodone)

Other substances 38 percent of those who had not yet left the program (alcohol, amphetamines, barbiturates, benzodiazepines, cannabinoids, and cocaine)

Note that those figures for other substances abused are predicted to be underestimates because

Drug screens can be and are relatively easily and often defeated

Other opioids screened for appeared to include heroin or oxycodone, not additional opioids (like Subutex, fentanyl, others)

Commonly and increasingly abused over-prescribed substances including gabapentin and quetiapine were not screened for

Those results fit with the more recent observations of these researchers, commenting on prevalence of abuse of illicit opioids during OST and after ending use of substitute opioids, comparing buprenorphine to heroin –

From results of an 11-state survey, patients in medically-supervised OST (bupe) programs use additional opioids or other drugs of abuse at high rates, constituting misuse, and do not retain in treatment and/or return to other opioid use after medical OST “treatment”.

“Because the study data lacked information on patients’ use of illegal opioids like heroin, the results likely underestimate the proportion of patients using opioids during and after buprenorphine treatment. “The statistics are startling,” says Alexander, “but are consistent with studies of patients treated with methadone showing that many patients resume opioid use after treatment.” [emphasis added]

And writing in Commonwealth Magazine (without links to original material) describing use of methadone and buprenorphine in correctional systems in Massachusetts and other New England states, Andrew Klein (identified as Senior scientist for criminal justice, Advocates for Human Potential) –

Second, it may be problematic to continue individuals on opioid medication if they are unable or unwilling to abide by the rules. The Middlesex jail, for example, has found that the majority of individuals entering with prescriptions for methadone or buprenorphine are mixing their prescribed medications with additional narcotics, benzodiazepine, and alcohol. A large Medicaid study across New York documented that more than a third of persons being treated for opioids using agonist medication (medication that activates the opioid receptors in the brain) were obtaining narcotic prescriptions outside of their maintenance prescriptions.[i] In one instance, an individual was found to have received 49 prescriptions for hydrocodone, oxycodone, or methadone while on medication assisted treatment for opioids. Both increased doses and mixing of medications while on agonist maintenance can make overdoses more likely.

. . .

Studies increasingly reveal that diversion of medication, especially buprenorphine, is the rule, not the exception, in the community. With a study finding that more than 11,000 children and adolescents were reported to poison control centers for exposure to buprenorphine between 2007 and 2016, the last thing jails and prisons should be doing is increasing that deadly exposure in the community.

Again, it can be presumed that these are underestimates of abuse of prescribed methadone, including high-risk abuse with other sedating drugs, unless each program measured comprehensively (and from these reports, these programs did not) a full range of commonly abused substances including in addition to “narcotics” synthetic illicit fentanyl and fentanyl analogs and prescribed medications commonly abused for sedative effect including quetiapine and gabapentin.

The reported widespread abuse points to prescribed opioid substitutes including methadone and buprenorphine being used most frequently for sedative/euphoric effects at elevated risk and potential public health costs, rather than by individuals motivated for reducing dependence and for gains in personal, community and social functioning.

And from this recent study in the UK –

One confounding factor common to the inappropriately interpreted studies is that subjects provided OST were typically followed up with for short durations through provision of OST and after the “treatment”. A recent, large UK study is relatively more robust, powerful and externally valid because a large number of opioid-dependent patients (11,033) in natural care settings – not under supervision or criminal justice mandates and controls – were followed up to 12 months after end of treatment, potentially moderating confounding effects due to presumed greater exposure to protective effects of naloxone responders while engaged in community services and recovery-supportive environments.

That study’s conclusions appeared to attribute no significant overall reductions in risk of opioid-related overdose deaths (“drug related poisonings” = DRP) associated with buprenorphine or methadone OST, “Model estimates suggest that there was a low probability that methadone or buprenorphine reduced the number of DRP in the population: 28 and 21%, respectively.”

HOW HAS RADICALLY LIBERALIZING AND EXPANDING DISPERSAL OF ADDICTIVE SUBSTITUTE OPIOIDS OVER PAST DECADES WORKED OUT IN FRANCE ?

In France, a decades-long experiment liberalized provision of buprenorphine (Subutex and Suboxone), promoting and allowing essentially unrestricted dispersing of the substitute opioid as a fix for the country’s opioid problem and with these predictable results:

Consistent evidence – as the national dose of substitute opioid medical “fix” and “anti-addiction drug” buprenorphine has steadily and substantially increased – of a concurrently worsening, lethal epidemic – outlined in this post:

More Signs U.S. Medical Industry Magic Pill Approach to Opioid Crisis on Same Track as Decades-Old Failed French Experiment of Unrestricted Buprenorphine Prescriptions in Primary Care

Rampant, runaway diversion and abuse of the prescribed, addictive substitute opioids in France and the U.S., enough in France to fuel buprenorphine abuse epidemics in another country –

The French Connection France’s Decades-Long Unrestricted Buprenorphine (Substitute Opioid) Campaign – Promoted as the “Fix” for U.S. Opioid Crisis – is Fueling Widespread Prescribed Opioid Diversion, Trade and Abuse

Lack of evidence to support the claim of efficacy for MAT/OST in reducing OD deaths or for other benefit, instead evidence for diverse harms – described in this post:

The Science: Following French Failure, Americans Get a Substitute Addictive Opioid as “Fix” for the Opioid Crisis, Marketed as Reducing Overdose Deaths Does It?

OST falsely constructed, branded as “treatment” thereby diverting public resources, attention, and policy away from existing evidence-based treatments for problem substance use including opioid use –

Opioid Epidemic: For Worsening Crisis French and U.S. Medical Systems Dispense Ongoing Addictive, Abused Substitute Opioids With No Evidence-Based Treatments, Predictable Outcomes

Evidence falsifying and dismantling claims by the medical/harm-reduction industry that diverted substitute opioids are primarily or largely used in self-treatment by individuals motivated to stop high-risk opioid use, instead affirming misuse and abuse of diverted prescription opioids – described in this upcoming post:

Update, Opioid Crisis – Word from the Street: The Bupe Economy is About Abuse not Self-Treatment

And remarkably lax, non-compliant, incompetent, and negligent levels of provision of addictive substitute opioids by the barely-regulated physicians –

For Worsening Crisis U.S. Medical System Dispenses Addictive, Abused Substitute Opioids With No Evidence-Based Treatments, Predictable Outcomes

More Specifically,

Observations noted in this 2015 report linked widespread diversion, trafficking, and abuse to the “pill mill” characteristics of the French “framework for its prescription”:

“Its wide availability linked to the framework for its prescription and the possibility of injecting it has promoted its misuse,” reveals a study by the French drug and drug addiction observatory Observatoire Français des Drogues et des Toxicomanies.

And, “How can a doctor provide real patient care when dealing with 300 drug addicts? At this stage, all they are doing is renewing prescriptions.”

An earlier look described French doctors as untrained and unprepared to understand the needs of substance users, instead serving as dispensers of the substitute opioids:

“The French system encourages physicians unfamiliar with addiction to prescribe buprenorphine and trusts patients to use it properly. . .”
Including the interviewed doctor who “does not screen patients to ensure that they, in fact, are opiate-dependent and need treatment.”

“Because of its widespread availability, Subutex was serving as a first opiate for some drug users and a re-entry opiate for some who had previously injected heroin. The report found it to be highly addictive and hard to stop. And it was increasingly being used in dangerous combinations with alcohol, benzodiazepines (such as tranquilizers) and even cocaine. . .”

“Many stay in treatment for years, including some who want to quit, prompting criticism that substitution therapy doesn’t address the underlying problem of opiate dependence.”

A more recent report on prescriber practice is consistent with concerns that French model opioid use “treatment” is not so much treatment as it is unregulated and dis-integrated provision of the substitute opioids. Results of the  2015 report on French physician adherence to guidelines aimed at protecting patients and the public from diversion and abuse of a widely-prescribed addictive opioid are troubling and appear explanatory:

“We showed that the physicians we interviewed rarely took into account the guidelines regarding buprenorphine prescription. The actual prescribing of Buprenorphine differed from the guidelines. Only 42% of independent Family Physicians (FPs), working outside the national health care system, had prescribed buprenorphine as a first-time prescription and 40% of FPs do not follow up patients on buprenorphine. In terms of compliance with the guidelines, 55% of FPs gave theoretical answers that only partially complied with the guidelines.” [despite that] “physicians declared a high rate of participation in continuous addiction therapy training. 38% of FPs and more than 80% of Network or Hospital physicians reported having attended continuous medical training (CMT) in addiction therapy.”

SO MUCH FOR THE FRENCH FIX FOR THEIR OPIOID PROBLEM.

LET’S GET BACK TO THE RESEARCH “PROVING” REDUCED MORTALITY OF 50 PERCENT AND MORE FOR OST IN THE U.S.

Other factors associated with engagement in OST services are, unlike use of the substitute opioids, supported by evidence as predicting protection against high-risk opioid use and against overdose by opioids resulting in mortality, the measure used in this study.

The factor known to predict reduced overdose mortality for opioid high-risk use and overdose is the OD death-reversing opioid antagonist naloxone. Subjects engaged actively in OST services would be predicted to be at increased likelihood of access to naloxone and to naloxone response in case of overdose compared to subjects outside of those services for a number of reasons

For both intrinsically and extrinsically motivated subjects, regular contact in a clinical setting providing OST would increase exposure to support for repeated training, provision, and encouragement to carry and use naloxone and to engage significant others in training and carrying for use.

Both types of OST subjects would be predicted to be more involved in protective social and professional settings, and for more time, than those outside of OST services – settings with health, community corrections, and social services personnel likely prepared to facilitate or provide naloxone support, compared to return to living conditions with less engagement.

Mandated subjects, whose exit from OST engagement may likely be associated with end of mandates, would be expected, through additional conditions, to engage in such protective, structured settings including: behavioral health and or skills training services; community service involvement; parent skills training; supported housing; domestic violence support; training and employment programs, other.

Subjects not mandated, instead engaged in OST services out of intrinsic desire for change, would for other reasons be expected as driven by the same motivation during an episode of OST involvement to engage in similar protective settings and supports, exposing them to the protective factor of community engagement.

Those factors are established and predicted by evidence to be protective against high-risk use associated with overdose death – especially as increasing exposure to social/professional support settings with high likelihood of naloxone response – despite the established association of use of methadone and buprenorphine with enmeshment in street economies of diversion and abuse.

In addition to facilitated naloxone response, regular contact in a medical setting during versus after OST services involvement would increase likelihood of medical attention and supports for comorbid conditions that would increase risk of lethality with opioid overdose – factors not as likely to be provided to patients once outside of OST services providing regular medical contact: routine visual contact with “vitals” taken; blood draws/drug screens with monitoring and corrective control of additional medications with CNS depressant (sedating) effects; medical monitoring and treatment of comorbid conditions increasing risk of opioid overdose resulting in lethality including respiratory and heart problems, sleep apnea, infectious diseases related to high-risk opioid use, other.

While factors associated with OST engagement, in contrast to use of the substitute opioids, are predicted by evidence to be protective against the outcome measure of mortality – other associated factors are predicted by longstanding evidence to instill risk factors for return to problem substance use. – risk that would elevate probability of high-risk use and mortality on return to less protective environments.

The medium or setting itself – visits to a medical office or clinic for services for a substance use problem – is expected to encourage belief in the disease model of substance use, a fabrication belief in which is established by evidence as a key predictor of relapse.

Another key predictor of success versus return to problem substance use is the trait of self-efficacy.

Every visit to a medical office or provider for a substance use problem causes harm by instilling and reinforcing false belief in a passive, ineffective medication, a pill for a complex, individualized inner reality of potent early experiences, psychological injury, distress, distorted beliefs and associated mood states – an individualized inner reality with only collaborative, extended work in psychotherapies as indicated treatments – disincentivizing patients engaged in a potentially lethal compulsive behavior (the symptom of that inner reality) away from engaging in the more intensive, active work of counseling and behavioral changes. Predicting continued distress, illness and harm.

Self-efficacy: The Opposite of Helplessness and Powerlessness

Self-efficacy is the developed sense of confidence in one’s own choices, abilities, and effectiveness to make the changes needed to resolve a problem or regain health and safety.

Self-efficacy is developed, reinforced, experienced and strengthened in a process of interaction with skilled therapists over which experiences that include active changes (not passive changes like taking a pill) are experienced as effecting positive changes in the patient’s life and resolution of problems.

That is, a key factor established by research as required to stop and protect against return to problem substance use requires work in therapy over time in order for patients to internalize, own, and self-affirm personal agency and effectiveness, control, in behavioral and other changes that protect against problem substance use.

Medical visits and the sham “treatments” are a barrier to self-efficacy, that is a barrier to healing and wellness. That process is subverted when vulnerable patients are reinforced, by medical visits for a non-medical problem – in the false belief of a passive fix for substance use, a pill.

The trained belief in a non-existent condition “addiction” as a medical condition with medical treatments was predicted, all along, to generate illness, “treatment” failures, ultimately lethal epidemics.

Summing up so far –

mounting, direct evidence establishes that increased availability and use of the OD death-reversing drug naloxone accounts directly for any apparent moderation of worsening trends in opioid-related overdose deaths and is a confounding factor in studies cited uncritically as “proof” of mortality-reducing benefit from substitute opioids, for which there is no credible evidence.

So much for the evidence proving that OST reduces opioid-related mortality.

What about “keeping people in treatment” ?

Lopez in Vox also claims also that opioid substitute “medications” “do a far better job of keeping people in treatment than non-medication approaches” based on this review of studies, implying that buprenorphine and/or methadone provision were compared to psychotherapy or psychosocial supports as treatment.

Huh. There were no “non-medication approaches” in the studies reviewed, just bupe, methadone, and placebo, with mixed results and high rates of illicit opioid use in the trials, as we knew.

SELECTION CRITERIA:

Randomized controlled trials of buprenorphine maintenance treatment versus placebo or methadone in management of opioid-dependent persons.

Let’s take a look again at retention rates in methadone and bupe OST programs, from multiple studies in natural community settings – that is, with high external validity = high confidence that results apply to real world settings. Methadone retention is at the top:

Again, the top line is for methadone, with retention (patients staying in the program to utilize the “treatment” and associated supports to reduce high risk opioid use) at less than 50 percent at 180 days and clearly, as for Subutex and Suboxone, trending downward.

Substances abused (detected in urine screens) for methadone users included:

Other opioids – 17 percent of the 48 percent methadone participants remaining at 180 days (heroin or oxycodone)

Other substances 38 percent of those who had not yet left the program (alcohol, amphetamines, barbiturates, benzodiazepines, cannabinoids, and cocaine)

Note that those figures for other substances abused are predicted to be underestimates because

Drug screens can be and are relatively easily and often defeated

Other opioids screened for appeared to include heroin or oxycodone, not additional opioids (like Subutex, fentanyl, others)

Commonly and increasingly abused over-prescribed substances including gabapentin and quetiapine were not screened for

So much for retention.

The very same single meta-analysis used by Lopez to promote the unsupported claims of reduced mortality – inconclusive at best and coming with the warning from the authors that “. . . further research must be conducted to properly account for potential confounding and selection bias in comparisons of mortality risk between opioid substitution treatments, as well as throughout periods in and out of each treatment.” – is cited by another research-illiterate (lacking in training or competence to understand, interpret or critically evaluate research) popularizing writer here, Zachary Siegel writing in the Columbia Journalism Review.

Repeating the branding slogans supporting OST that Go Without Saying, Siegel cites a review article to support the same claim Lopez makes about opioid substitution medications “keeping people engaged in treatment”.

Before diving into the study’s results, it’s important to review the science about the medications in question. Medications do a better job at keeping people engaged in treatment than traditional abstinence-based approaches that rely on group therapy, counseling, and the 12 Steps.

Most relevant to the current overdose emergency, methadone and buprenorphine, in particular, reduce one’s risk of fatal overdose by more than 50 percent. Both drugs are considered the “gold standard of care” in the scientific literature, and the World Health Organization lists them as “essential medicines.”

. . .

Dr. Alister Martin, one of Dr. Wakeman’s colleagues at Mass General, leads the “#GetWaivered” campaign aimed at getting more doctors to prescribe buprenorphine. While he’s focused on getting more doctors to step up and play their role, Dr. Martin says that the media has to do better, too.

“The data is clear,” he says. “Medications for addiction treatment save lives and as long as we continue to make it harder for patients to get help than it is to get high, we’ll struggle to overcome this crisis.”

Encouraged by its journalistic achievements, Vox followed up about a year later with another piece based on the writer’s evaluation of the research and evidence supporting OST and the “two gold standard medications for opioid addiction”.

A growing body of research suggests that a major part of Obamacare, the Medicaid expansion, is playing a significant role in fighting the deadly and growing opioid epidemic.

The latest study, published in Health Affairs by Brendan Saloner, Rachel Landis, Bradley Stein, and Colleen Barry, found that after West Virginia expanded Medicaid, the number of people diagnosed for opioid use disorder under the public insurance program rose — and, crucially, the number of people on buprenorphine, one of two gold-standard medications for opioid addiction, went up as well.

. . .

Studies show buprenorphine and methadone reduce the mortality rate among opioid addiction patients by half or more and keep people in treatment better than non-medication approaches.

Here’s some additional research evidence explained by Vox as establishing bupe and methadone as a gold standard – by expert consensus – and the solution to America’s lethal opioid crisis.

The state started the program, the Addiction and Recovery Treatment Services (ARTS), in April 2017. Although ARTS is still fairly new, independent evaluations from researchers at Virginia Commonwealth University (VCU) have already found some promising results.

After the program went into effect, the percent of Medicaid members with an opioid use disorder who received treatment went up by 29 percent from April to December 2017 compared to the same period the previous year. At the same time, emergency department visits related to opioid use disorders went down by 31 percent. That was more than double the 15 percent reduction in emergency department use among all state Medicaid members during the same time frame.

The researchers also calculated what they would expect emergency department visits to look like with and without ARTS. The model suggested that ARTS really is to credit for the bulk of the drop in emergency department usage.

Vox Virginia ARTS prog

ARTS is a program that provides medically-prescribed buprenorphine (Suboxone) to individuals struggling with compulsive opioid use.
And more. Like placement in residential treatment.

The ARTS program offers the full gamut of treatment options, from outpatient doctors’ offices to intensive residential facilities. “We built a whole continuum of care,” Katherine Neuhausen, the chief medical officer of Virginia Medicaid and an architect of ARTS, told me.

Patients are placed in treatment depending on their needs, based on guidelines by the American Society of Addiction Medicine that use a numerical scale to figure out the intensity of treatment that’s required.

In residential facilities, of course, patients are monitored, provided some level of medical attention and services, and are in a comfortable environment off the streets and with food provided. An environment where they are not exposed to the stressors of street life and street drugs.

ARTs services include “coverage for residential treatment and medically managed intensive inpatient services for substance use disorders”. Most services are provided in outpatient settings.

From a 2017 program report

ASAM Level 2 includes partial hospitalization and intensive outpatient services. During the first 5 months of ARTS, 386 members used these services, including 150 members with an opioid use disorder.

ARTS added coverage of short-term residential treatment services (ASAM Level 3) and medically managed inpatient services (ASAM Level 4). During the first 5 months of ARTS, more than 1,200 members used medically managed inpatient services for substance use disorders, while 83 members used short-term residential treatment services.

The ARTS program has worked to accomplish reductions in co-prescription of medications like benzodiazepines and other opioids with  that add to risk of overdose and lethal overdose when used with  OST prescribed opioids.

And,

in Virginia, legislation, training, incorporation into OST treatment services, and provision of the opioid OD death-reversing drug naloxone has increased along with and part of the expanded services.

Let’s sum up. In Virginia –

1) Increased placements of problem opioid users in protective residential facilities; 2) expansion of patient contact with service settings promoting and facilitating dispersal and use of OD death-reversing naloxone; 3) decrease in provision of overdose risk-increasing medications like benzodiazepines and other opioids –

each independently, or in combination, able to account for a concurrent decrease in opioid-related ED visits.

No evidence to support effectiveness for the “anti-addiction medications like buprenorphine and methadone” promoted as “treatment” and beneficial in addressing America’s worsening lethal opioid epidemic.

SAMSHA bupe client trends2

The more medical gold standard fix provided to diseased brains, the more deaths mount.

Overdose deaths US trend The Guardian

(from The Guardian – November 29, 2018)

A media strategy of doubling down on dumb and compromised popularization of the unvalidated OST fix, repeating the type of public health disinformation that drove and enabled the opioid crisis, is not likely to be helpful, instead to ensure additional harm to vulnerable Americans trapped in lethal substance use epidemics.