It's Time For Physicians To Support The Maintenance Model
March 10, 2006 Commentary By Jeffrey Baxter, MD
Imagine if diabetes were treated like opiate addiction.
When your blood sugars or dietary habits are poorly controlled, you are sent to a 5 day sugar detoxification program, or 30-day rehabilitation program, and then considered cured. What if your doctor stopped your insulin when you relapsed to eating sugar again, or even discharged you from the practice for "non-compliance"? What if, after you stabilized your diabetes on insulin, your doctor insisted that you "detox" off of insulin, or told you that your dependence on insulin was just covering up your addiction to sugar?
The comparison to Type II diabetes is helpful for developing an understanding of opiate addiction as a chronic disease. Both illness have genetic components and run in families. Both are lifelong conditions that are affected by the lifestyle choices that each individual makes. And both diseases have well-defined pathological processes that respond well to medical treatment. Why, then, do we treat these chronic illnesses in very different ways?
Comments made by a Boston-area physician in the Boston Herald March 5th (Suboxone Catches On in New England, 3/6/06) highlight the persistent gap between the current clinical practice of treating opiate addiction and the extensive body of evidence demonstrating that opiate maintenance, like insulin "maintenance," is the most effective treatment for this condition.
This physician stated that outpatient Buprenorphine treatment was like giving "candy" to patients with opiate addiction. He further went on to say that he would not treat outpatients with buprenorphine because he feared he would not be able to get these patients off the medication. These comments show a either a complete ignorance or a complete disregard for numerous studies conducted over the last 40 years supporting the effectiveness of opiate maintenance therapy in decreasing drug use, overdose deaths, crime, and HIV transmission in patients with opiate addiction. Calling buprenorphine "candy" for patients with opiate dependence is likely calling insulin "candy" for patients with diabetes: pure nonsense.
Opiate maintenance is one of the best studied and most effective medical therapies in existence today. Studies have shown that methadone maintenance decreases crime and drug use by 80%1. In one study, maintenance treatment reduced HIV infection rates from 26% to only 5%2.Maintenance improves employment rates and social functioning3, and provides $4 in benefits to society for every dollar spent4.Moreover, maintenance reduces the death rate for patients with opiate addiction by over 60%5. Any other treatment that achieved these results would be considered a medical breakthrough, yet physicians and addiction professionals around the country continue to oppose or ignore the practice and the evidence supporting it.
Buprenorphine is a life-saving medication for people with a serious and life-threatening chronic illness, and a remarkable innovation in the treatment of opiate addiction. It is a safe alternative to methadone maintenance and is bringing patients into treatment who are younger, earlier in the course of addiction, and who never have been treated before6. In the first three years of its use, buprenorphine is showing great promise in meeting the treatment needs of hundreds of thousands of opiate addicts who have either not been able or not been willing to enter treatment in the past.
Opiate abuse has reached epidemic proportions in Massachusetts. According to the Massachusetts Department of Public Health, from 1999 to 2003, opioid-related fatal overdose rates increased by 71% and rates of opioid-related hospitalizations increased 68%. In 2004, there were 573 opiate overdose deaths, more than the number of people who died in traffic accidents. The abuse of pharmaceutical opiates has become such a problem that the legislature in Massachusetts has gone as far as proposing legislation to ban the sale of Oxycontin statewide.
At this critical juncture it is time for physicians in Massachusetts and nationwide to put aside their personal biases and support the maintenance model for treating opiate addiction. The evidence is clear: maintenance works, both with methadone and buprenorphine. Detoxification, regardless of the method or medication used, results in patients dropping out of treatment and relapsing to drug use7. It is irresponsible and dangerous for medical professionals to send mixed messages about what treatment is effective for opiate addiction. Uninformed comments that may keep patients with opiate addiction from receiving effective treatment will cost these patients their lives.
Dr. Baxter is an Assistant Professor at the University of Massachusetts Medical School in the Department of Family Medicine and Community Health.
- Ball, J.C; and Ross A., The Effectiveness of Methadone Maintenance Treatment: Patients, Programs, Services and Outcomes. New York: Spring-Verlag, 1991.
- Metzger, et al, HIV Seroconversion among In and Out of Treatment Intravenous Drug Users: An 18th-month prospective follow-up. AIDS (6) 9, 1993: 1049 -56.
- Lowinson, Joyce H., et al, Methadone Maintenance. In: Substance Abuse: A Comprehensive Textbook, Second Edition, Lowinson, J.H.; Ruiz, P; Millman, R.B.; and Langrod, J.G., editors. Baltimore: Williams & Wilkins, 1992, pp. 550-561.
- Harwood, H.J.; Hubbard, R.L.; Collins, J.J., and Rachal, J.V. The costs of crime and the benefits of drug abuse treatment: a cost-benefit analysis using TOPS data. In: Compulsory Treatment of Drug Abuse: Research and Clinical Practice (NIDA Research Monograph Series). Rockville, MD: DHHS 1988.
- Anonymous (1998). "Effective medical treatment of opiate addiction. National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction.[see comment]." JAMA 280(22): 1936-43.
- Sullivan, L. E., M. Chawarski, et al. (2005). "The practice of office-based buprenorphine treatment of opioid dependence: is it associated with new patients entering into treatment?" Drug and Alcohol Dependence 79(1): 113.
- Collins, E. D., H. D. Kleber, et al. (2005). "Anesthesia-assisted vs buprenorphine- or clonidine-assisted heroin detoxification and naltrexone induction: a randomized trial.[see comment]." JAMA 294(8): 903-1.