July 27th, 2016
Imagine there were a class of medications that could cut your risk of dying from one of the most deadly disorders in medicine—by half or more.
Now, consider that your access to these drugs could be arbitrarily ended if you showed some of the symptoms of that condition—or that you might not be provided with these medications in the first place, because the government limits the numbers of doctors who are allowed to prescribe, regardless of local needs. Imagine, too, that you could be cut off from receiving these drugs because you didn’t attend enough required counseling sessions—even though being denied these medications exponentially multiplied your risk of dying in the days immediately following.
America wouldn’t stand for any of this in diabetes or cancer care. Yet it’s par for the course in maintenance treatment for opioid addiction—the only approach that is consistently shown to cut the death rate by 50 percent or more.
Even the much-touted Comprehensive Addiction and Recovery Act (CARA) legislation, which Congress just passed to try to address the opioid problem, doesn’t remove the limits on maintenance treatment: It merely increases the number of buprenorphine maintenance patients a doctor is allowed to see (after getting extra training) from 100 to 275, and does little to ease restrictions on methadone. CARA also doesn’t change the fact that addiction is the only medical disorder in which access to lifesaving drugs may be—and often is—denied because of noncompliance with unrelated elements of treatment, without fear of malpractice judgments.
Here’s the problem. The very term “medication-assisted treatment” (MAT) reflects the reality that most people with addiction require more than simply being handed a pill or a cup of liquid medication in order to get better. Many need psychiatric care, counseling, training in relapse prevention, jobs, housing and other diverse forms of and support. No one would argue otherwise.
But it does not follow from this indisputable premise that forcing people who want MAT to participate in counseling and requiring abstinence from illegal drugs in order to get it are the best ways to help. In fact, this policy is probably having deadly results for two reasons—both because the restrictions directly deny some people access to care and because they indirectly use resources that could be better targeted. (In this column, I’m focusing only on maintenance treatment with methadone or buprenorphine; MAT with antagonist medications like naltrexone has not been shown to reduce mortality).
While nearly all experts agree that social support is a critical part of recovery, it’s rather hard to force people to make friends or to find comfort in groups or people they do not like or trust. Nor has anyone figured out a way to coerce people who simply do not believe they can live good lives without opioids to immediately change that perspective in a lasting way.
Moreover, much of the life-saving effect of drugs like methadone and buprenorphine is simple pharmacology: If someone has a regularly high level of opioids in their system, tolerance (and in the case of buprenorphine, receptor-binding properties) means that it is much more difficult (and expensive) to overdose.
Given these facts, it’s hard to argue that denying people maintenance access for their failure to stay drug-free, or because they’ve missed or refused counseling appointments, makes sense.
Indeed, there’s little evidence that mandatory counseling adds much to the lifesaving effects of maintenance. The data that exists favors pharmacology.
This became clear during the AIDS epidemic in the late ‘80s and early ‘90s. Researchers found that providing what they called “interim” methadone maintenance—i.e., methadone without counseling or any other requirements or support—had dramatic, positive effects.
For example, a 1991 study randomized 301 people with heroin addiction seeking maintenance in New York to either remain on a waiting list or receive immediate, low-threshold methadone treatment. At intake, around two-thirds of participants tested positive for heroin—after one month, that remained the same for the control group but fell to 29 percent (i.e., more than cut in half) for those given methadone. And six months later, 72 percent of the treated group remained in treatment, compared to just 56 percent of controls. A 2006 study had similarly impressive results.
A Cochrane review that compared data on over 4,300 patients in 35 studies to see whether more intensive counseling or different types of counseling could improve outcomes compared to standard programs found no difference: Basically, the outcomes were the same and the drug itself, rather than the ancillary services, was the active ingredient.
More recently, studies have been conducted to see whether the same is true for buprenorphine. Although only pilot testing has been published so far, it found that 57 percent of those who started in a low-threshold program were successfully transferred to a traditional program that included counseling within a month and a half, and 83 percent stayed in treatment for at least nine months.
Consequently, there’s no rational reason that low-threshold access to buprenorphine or methadone should not be offered to everyone who wants it. This doesn’t mean just handing out drugs willy-nilly: In order to prevent double-dosing, people should have to register and be observed taking the drugs in order to ensure safety.
With those safeguards in place, however, people with opioid addiction should be able to get dosed as needed—because any time they take a maintenance dose rather than street drugs, harm is being reduced. Whether someone just wants to avoid withdrawal for a day, or whether they are considering making a bigger change but aren’t yet ready, everyone who wants harm reduction should have access. This would benefit not only the people directly involved but everyone else too, by reducing costs, crime and disease.
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Making this change would also have a salutary effect on maintenance treatment more generally: Those who just want the drugs would not have to go through the ritual dance of urine testing and counseling simply to be dosed—and those who are working to stabilize wouldn’t have to interact with such disengaged folks in their groups. Counselors would see patients who want long-term recovery, not people just seeking to placate or tolerate them in order to avoid withdrawal. Resources would be directed where they are needed, not wasted on those who don’t want them and won’t benefit, while people who need lifesaving care are shut out.
No one would deny insulin to people with diabetes who are not always compliant with their diets, or deny high blood pressure medication to those who don’t exercise to reduce hypertension. So why is this acceptable in addiction? The answer is depressingly familiar: because we don’t really see it as a medical issue, but as a moral failing.
Maia Szalavitz is a columnist for The Influence. She has written for Time, The New York Times, Scientific American Mind, the Washington Post and many other publications. She has also authored six books, including Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids (Riverhead, 2006). Her latest book is Unbroken Brain: a Revolutionary New Way of Understanding Addiction. Her last column for The Influence was “Do We Need Trigger Warnings for Depictions of Drug Use?” You can follow her on Twitter: @.