No, Methadone is not the New Methadone

by Clark Miller

February 13 , 2019

The false promise of medication assisted treatment = MAT (or opioid substitution therapy = OST) is increasingly exposed as a deceit by critical evaluation of diverse lines of evidence and research from U.S. MAT outcomes and from France’s decades-long, least restrictive, most intensive opioid substitute treatment (OST) campaign in the world, held out as the model for a U.S. medical “fix” by provision of substitute opioids.

As is the case for the lethal iatrogenic opioid crisis that fix is a response to, the “research evidence” and overtly reckless and unethical practices were never credibly supportive and predictive of benefit, instead predicted addiction and the opioid crisis, now the mounting body of evidence of failed outcomes and steadily worsening lethal public health epidemics as population “dose” of the medical cure increased substantially and steadily in the U.S. and model country France. 

Research that was never subjected to competent critical analysis of research design, interpretation and validity, never subjected to a critical discourse, instead successfully spun, recklessly misread, distorted and endorsed and popularized in mass media.

Everywhere, Signs of a problem:

1) as public healthcare resources are increasingly devoted to a strategy of providing buprenorphine as a substitute addictive opioid, evidence mounts of failed effectiveness and of diverted “bupe” instead driving economies of abuse and

2) new powerful synthetic opioids hitting the street in an ever-evolving economy of addictive need seem to be neurochemically outcompeting, overwhelming presumed protective effects of the “anti-addiction” drug.

 

Signs enough

for major media calls for a return to methadonemethadone, the more dangerous, more addictive substitute opioid bupe replaced – to become the new-old medical cure for the non-medical condition of compulsive substance use and for America’s worsening lethal, medically-generated opioid crisis.

Methadone!

Some observers – media writers – surveying America’s wasteland of uncontrolled epidemics, seem to glimpse dimly the writing on the wall: the clear indications of the endorsed-by-consensus, increasingly funded, medical substitute opioid fix failing as a treatment, or even as harm reduction, overdose deaths sharply rising the more fix is provided, that substitute opioid fix functioning instead as an integral product and currency in illicit economies of abuse and illness.

And surveying that grim landscape have begun casting about for an alternative to today’s gold standard,  buprenorphine, for another medical fix (because problem opioid use like all problem substance use is, after all, a medical condition, a disease of the brain. Isn’t it?), generously offering the treatment recommendation of easing restrictions on and expanding provision of methadone, the substitute opioid replaced by bupe based on higher risk of abuse and overdose for methadone.

These writers wondering if it wouldn’t make sense to re-allocate, re-divert, public healthcare funds away from the failed Suboxone campaign and to methadone programs, more than that, to more relaxed and extensive provision of the addictive, abused opioid methadone, by relaxing federal guidelines and restrictions enacted to protect patient safety.

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) –

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.

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

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.”

Reporters glimpsing dimly the writing on the wall and missing, blinded to, the graffiti next to it. 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.

Blinded to the signs on the street, to the clues at the methadone clinics. 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, concluding –

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.”

(Rhetorical Question Alert)

What types of outcomes might we predict from easing patient safety regulations and controls on dispersing of methadone, an opioid with significantly greater euphoric effect, greater potential for abuse and lethal overdose than buprenorphine?

Here’s one clue, from Quinone’s Dreamland (p 190) –

Generic methadone, for years strictly an addict-maintenance drug, suddenly started killing, too. As media reports of OxyContin abuse and overdoses spread, some doctors began prescribing methadone for pain instead. . . some doctors figured that methadone was an equally long-lasting painkiller. Plus methadone was generic and cheap; insurance companies covered it. Methadone prescriptions more than quadrupled – from under a million in 1999 to 4.4 million in in 2009 nationwide – mostly for headaches and bodily pain.

. . .

As methadone prescriptions rose, so did overdose deaths involving methadone – from 623 in 1999 to 4,706 in 2007.

But,

the established level of competence and dedication to ethical, thoughtful and informed practice by the American medical system is protective, would guarantee safety and welfare of vulnerable and all Americans, with any new fix for the opioid crisis.

Wouldn’t it?

From that report, in JAMA

Researchers sketched a vivid line Friday linking the dollars spent by drugmakers to woo doctors around the country to a vast opioid epidemic that has led to tens of thousands of deaths.

The study, published in JAMA Network Open, looked at county-specific federal data and found that the more opioid-related marketing dollars were spent in a county, the higher the rates of doctors who prescribed those drugs and, ultimately, the more overdose deaths occurred in that county.

. . .

And they noted that marketing could be subtle or low-key. The most common type: meals provided to doctors.

Meals.

It turns out, after all, that the diversion of pubic heath resources to provide inappropriate medical interventions for non-medical problems predicts harm.

Who knew?

Who could have known?

All of us, actually – if healthcare, research, scientific and professional publication, and oversight systems had been simply performing legally, competently and ethically. If critical thought, critical analysis of research, and ethical reasoning had not been abdicated and overpowered by constructed, useful fictions. And if media had been performing the role of journalism, providing truths available for decades.