The Rules Around Opioid Maintenance Would Be Seen as Unconscionable in Any Other Branch of Medicine

Jul 27 2016

The Rules Around Opioid Maintenance Would Be Seen as Unconscionable in Any Other Branch of Medicine

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.

Read more from The Influence:

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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 TimeThe New York TimesScientific 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: @maiasz.

  • The problem is not the people who insist that drug use is a moral failing. The problem is the people who insist it’s a disease or disorder, and that there is something wrong with the drug user, and that they need to ‘get better’. And that it is a ‘medical issue’ and that ‘relapse’ is a thing. These are all dangerous lies from people who should know better. Let people use drugs. There is nothing wrong with them. That’s what they do in Portugal and Switzerland and it works out fine. At least, much better than under the addiction caliphate here.

    • Patricia Williams

      I agree to a large extent. Although, having been a junkie for 15 years (now clean for 20), I would not recommmend heavy drug use to any child or friend of mine but, certainly, less hysteria, less legislation and interference with the doctor/patient relationship…Yes, people will occasionally kill themselves with opiates…Make access to Narcan easier. Allow those who wish to stop to determine the best way for them and for those with chronic pain and for terminal patients….being “dependent” on opiates is lots better than living or dying in an agony of pain.

  • Theresa Aines

    This would be funny if it weren’t so absurd! You’re complaining that there are too many hoops to jump through to get more opiods to opiod addicts because, golly gosh gee whiz, they’ve got a genuine medical “condition”. Well, I don’t hear anyone singing that same song for the millions of legitimate chronic pain patients who suffer from horrific diseases not of their own doing yet are unable to get any medical relief because of all the addicts out there creating an opiod “epidemic”. Chronic pain patients who have not used illegal street drugs or illegally diverted prescription opiods, and are not addicts are denied any sort of pain relief whatsoever or are kept on cumbersome and restrictive “opiod contracts”. They are often turned away by pharmacies even when they have a legitimate, legal prescription. Yet you want me to feel sorry for addicts who aren’t able to get more opiods so they don’t suffer a little withdrawal? What about pain patients who maintained for years on an therapeutic dose that allowed them to function then are cut off with no concern for either their pain or their withdrawal symptoms? Addicts should get the same “we don’t give a shit about your pain” treatment from the CDC/FDA/DEA and doctors that pain patients have to suffer under.

    • Patricia Williams

      I think those who have become dependent on opioids/opiates whether due to legitimate pain conditions or through careless abuse should be allies. Both would benefit from our government bureaucrats and politicians getting out of the doctor/patient relationship. I very much appreciated the Dutch attitude back in the 80’s where I could go to my doctor and say: ” hoops”, I allowed myself to become dependent on heroin and I want to stop….and he would give me a prescription for 3 weeks of methadone. It worked wonderfully IF you substitute and decrease the dose….The same doctor if I had terminal cancer or a chronically painful condition would have prescribed me opiates without having to look over his shoulder in fear. Why o why are we
      In the supposed land of freedom so determined to control every aspect of personal choices. By the way…I was a junkie for 15 years and have now been clean for 20.

      • Fleety420 .

        Keep up the good work friend!

      • Mooser42001

        ” It worked wonderfully IF you substitute and decrease the dose….”

        And any methadone clinic will reduce a clients dose at any rate they wish. As slowly as a milligram a month, if they like.

    • Patricia Williams

      Pain patients AND addicts DO get the same…”we don’t give a shit about your pain”. Mostly because the DEA etc has terrorized doctors into not prescribing adequate pain relief or else face losing their license. I wish all the politicians, bureaucrats and activists just got the hell out of the doctor/patient relationship.

    • ChinaSunflower

      Theresa, after 4 months of watching my brother die a slow painful death from stomach cancer, where we had to beg for every single dose of pain medication until I raised holy hell to get him on a pain management schedule and even then it was hydrocodone which gave the minimum amount of relief, to fighting about hospice care that wanted to send him home with a fentanyl patch and a once a week visit instead of the pain pump and daily care he needed, my eyes have been opened. I am horrified at what the new regulations for this ‘epidemic’ has meant for chronic pain sufferers, end of life and palliative care. I was fully prepared to get heroin on the street if that was what it took to ease my brother’s suffering because nobody seemed to give a damn and even if they did, were bound by these insane new restrictions. My brother had family and loved ones looking after him, I don’t want to imagine what it must be like for someone with no one to advocate for them. It shouldn’t be a question of either/or. After going through this, I really don’t give a good goddamn if some do become addicted through temporary or recreational use, these laws that inflict such unnecessary suffering are an abomination.

    • Terry Licia

      Actually, we have to jump through the exact same hoops as the addicts, including stupid ‘pain contracts’ that have absolutely no value except perhaps as a kind of blackmail! Baby Boomers are a huge lot of people, and we are aging, and we hurt. But an epidemic of abuse? NO. There have always been addicts, and there always will be, I suppose. The poppy is not anything new! The illegality of drugs is, by far, the biggest danger to our health! Get the government out of doctor/patient relationships, no matter who the patient is! We, the PEOPLE, need to stand up to this terrible invasion of our privacy, and … JUST SAY NO! There are a few doctors who do not observe these ridiculous laws, and more are cropping up every year but unfortunately, there are even more anesthesiologists turned “pain doctors” who are opening clinics up that do nothing but treat pain! It’s insane. They charge more, and do less, and are making millions in the process.

      Americans think they are so great, the best and brightest but in the last few decades, I’ve come to believe we must be some of the most ignorant people on the planet, and not a few of us are just flat out stupid! Until something truly horrible happens and swipes the headlines away from this latest ‘danger’ to the public, we will keep on being blackmailed and treated as if we were all ethically derelict because we hurt – physically or mentally. We have got to smarten up, and take back our rights. I don’t know HOW the masses can do it, but I’ve managed to ‘beat the system’ and get what I need for my pain. Maybe I should give lessons: “How To Get Your Pain Treated, Without Being Treated Like A Morally Bankrupt Patient” but I’m sure no one would listen to me, unless I charged them $200/hour!

      • ” How To Get Your Pain Treated, Without Being Treated Like A Morally Bankrupt Patient”? Terry Licia, please tell me where I sign up for the class!!

    • Lizzard Smith

      As a chronic pain patient I fully get it! We have been screwed by the ‘protective’ system badly. It is medical fact that opioid work. Yet a bunch of Washington know nothings have only made it harder for us with the lie that MDs made this happen. It is forgotten that a recently arrested cartel boss said he would flood the US with cheap heroin if a single state legalized cannabis. They did. He did. But few knew it was poisoned with cheap and easy to make fentanyl. Even fake prescription tablets have flooded the underground drug market with this same poison, coming from Mexico & China. The laws they passed only effect middle aged honest people who have little to no addiction problems. Like guns, if you are a criminal what law will stop you? Drugs are no different. While I see youngsters die daily in my small New England state very few are dropping from real phamacucial drugs but from overdoses of fentanyl in heroin or fake percocet. But for us that try to be honest and follow the rules we find as time goes on and a small increase in dosage is needed the MDs will not do it for fear of the DEA making their lives and careers a shambles. And Democrat or Republican the attitude is the same. Rush Limbaugh never spent a day in jail after an addiction that would have and in this case should have, sent him to jail for five or more years and my MD won’t raise my morphene by 5mg out of fear and was honest enuff to say so. The truth is out there but no newspaper cares because Trump going to Mexico is more important or Clinton’s emails. So we suffer in enforced silence and have no resort but alcohol. But I’m an alcoholic who hasn’t had a drink in 23 years. But I’m reconsidering that. If its all there is, my liver and Hep C be damned, I’ll do what I have to. We have a Merlot program but to save the $50 application fee and passport style photo on a disc is out of my budget and my insurance says they don’t cover it here, but do in in California. The list of legal stupidity goes on and on but I won’t bore you with it. We are too old and infirm to take to the streets now and can only live with Victims of the DEA & Congress stamped on our foreheads

    • Fleety420 .

      suffer a “Little withdrawal” are you even serious, I’d pay cash to see you go through a “LITTLE Withdrawal” Idiot, go back under that rock you came out from under to post

  • Irish

    Excellent article

  • Andrew_C_Bairnsfather

    I see this was published on the 27th of July. Not sure you saw it, but on July 15th the Boston Globe ran a headline “State to eliminate addiction copays: Connector joins fight against opioids.” I’d not yet read it (since I find the Globe horribly unpalatable) and also since the headline implied to me they were going to force people (already with little means) to bear the full cost of their meds. Let alone the horrible grammar (or anthropomorphism) of fighting inanimate pills.

    But for the sake of your article, this comment, and finally getting rid of that oldspaper, I read it. I was pleasantly surprised that “eliminate addiction copays” means the state & insurers will no longer require people to pay for methadone or suboxone (in addition to counseling I think).

    So although I hold Mass in low regard as far as being enlightened on the need to legalize drugs, this move as small as it is, seems in the right direction.

    That said, I agree with the other commenters who recount the horrible treatment they got from the medical world when they were in fact just plain old needy pain patients; I’ve been there on a few occasions. Sending a guy home with wimpy percocet pills after hernia surgery?!! Drug war at work, I was in agony! I’m too broken up to talk about the pain my dad went through before he died, no thanks to prohibitionist scum who pat themselves on the back about how they are “combating abuse” and “fighting addiction.” Scum sucking pigs.

  • Vegetarians Taste Better

    Well written article but I have mixed emotions.

    As a healthcare worker working with the homeless in a high drug use area, I agree in some ways that MAT with required therapies/drug tests can be cumbersome. Interim maintenance makes sense in many ways, especially with methadone, but I’m not sure how effective it would be with suboxone due to diversion and you’d need to watch the patient closely for some time to make sure it fully dissolves for clinic dispensing (which would nearly be impossible if you want to dose a lot of people). However, I’m interested to see what will happen when implantable buprenorphine is available (anyone have an update?).

    I find access to these therapies in a big city with a big problem horrible. Detox can be nearly unavailable (along with long term substance use program), wait lists for MAT, or behavioral health services in general, can be weeks to months long, and the cost is tremendous. If uninsured (applying for Medicaid takes at least a week, usually more, to become active), it’s hundreds of dollars to get an intake and dosed for a week.

    When someone comes to me and say they shoot 3 grams of heroin a day and they want to stop and I can’t help them because of the system (no detox beds, no insurance and no money, insurance needing prior authorization when the person doesn’t have a doctor, and so many more real examples I’ve encountered), it is a horrible feeling. To send someone away (with Narcan of course), knowing they need help and are asking for it, hoping that they don’t die from what they take overnight to try the process again tomorrow….

    The problem in this neighborhood in particular is massive and providers put their licenses on the line to provide these services which is why I think there are so many rules, guidelines, and contracts between the patient, prescriber, and the government. For example, there can be a lot of harm if the person is taking a lot of benzos or other meds to get a nod while on MAT.

    I don’t know what is right or the best way. This problem is difficult to conquer and it will take coordination from many groups but I think access and stigmatization are huge problems. I just wanted to share how difficult it can be for someone to get help where I work while at the same time having difficulty providing services to some patients.

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