The use of buprenorphine and other Medically-Assisted Treatments (MAT) for opioid use disorder has increased rapidly in response to the opioid epidemic in the United States. From the clinician’s perspective, buprenorphine seemed like a panacea. I remember feeling the same way about methadone in the 70s and Naltrexone in the 80s.
Buprenorphine’s unique chemistry, being a partial agonist and antagonist medication, meant patients were able to detox from heroin or powerfully addictive prescription pain medications using Suboxone (a trade name for buprenorphine) and then taper off with relative ease, compared to heroin or oxycodone. In some cases, patients were not able to come off of Suboxone and remained on a small maintenance dose for months, and even years, but had attained a quality of life they never believed was possible when addicted to illicit opioids.
However, a large study by the Johns Hopkins Bloomberg School of Public Health (2017) reports that a significant proportion of patients on Suboxone therapy, or shortly after the conclusion of their therapy, were attaining and filling prescriptions for other opioid medications. Outcome measures matter. Different treatments work if your outcome measure is one month of adherence to the treatment versus five years of drug-free outcome and return to work.
The methodology in the Johns Hopkins study reviewed pharmacy claims for over 38,000 persons who had been prescribed Suboxone between 2006 and 2013. The results were shocking. Two-thirds of these patients had filled a prescription for an opioid painkiller in the first 12 months following Suboxone treatment—while 43 percent had received a prescription for an opioid during Suboxone therapy. In addition, approximately two-thirds of the patients who received Suboxone therapy stopped filling prescriptions for it after just three months.
What These Data Cannot Tell Us
At first glance these data are disappointing. Just looking at patient return to the program over a short time like six months, it is very clear that most methadone patients come back and many Suboxone patients do not. However, there is much the study results don’t tell us.
In a clinical and policy environment where the number of prescribers, the volume and nature of opioid prescriptions, overdoses, prescribing policies, laws and regulations are changing frequently and dramatically, data loses some of their value. In Florida, for example, the legislature, in response to the “Pill Mills,” enacted a monitoring program whereby all prescribed scheduled medications were on a single database, accessible by any licensed physician.
Twelve months after implementation, the outcomes were evaluated. Overall opioid prescriptions decreased by 1.4%. Opioid volume decreased by 2.5%, and a decrease of 5.6% in MME per transaction was observed. These data were limited to prescribers and patients with the highest baseline opioid prescribing and usage. The findings also accounted for potential confounding variables including sensitivity analyses, varying time windows and dynamic enrollment criteria. The opioid landscape in Florida continues to improve, and the pill mills are virtually gone. This is just one example of how a state’s policies impact the data and the outcome in longitudinal research.
In addition, prescription drug monitoring programs (PDMPs) are associated with reductions in all drug use (including opioids). Data culled from adult Medicare beneficiaries in states that utilize PDMPs compared with states that do not have PDMPs show significant reductions in prescription opioid transactions. Moreover, the top treatment centers may prescribe buprenorphine but also set up voluntary drug monitoring and continuing care programs for their patients, much as the programs do for impaired physicians, nurses and pilots who mandate random and for-cause drug testing for five years.
Most heroin addicts have multiple drug dependencies and problems. They also have multiple medical co-morbidities. It is not as simple as switching the patient’s heroin for buprenorphine. But street heroin is more than a drug, it is many drugs and dangerous adulterants. Over 80 percent of the Physician Health Program participants are treated effectively, monitored and never had a positive drug test throughout the five years of post-treatment outpatient monitoring.
Lastly, the Institute of Medicine released their exhaustive report on Pain in America, revealing that 100 million Americans currently suffer from chronic or intractable pain syndromes. The Johns Hopkins study does not indicate what percent of the study participants have a pain syndrome, requiring treatment with opioid medication, hopefully under the supervision of a specialist in pain managements and addiction medicine.
Why Does This Matter?
The findings certainly raise questions about the effectiveness and the appropriateness of Suboxone for addiction treatment. Clearly, if we were to adopt an oncology standard of five years, Suboxone is not likely to be considered an effective treatment. But it is a viable and important option and part of an arsenal of treatment modalities used to individualize treatment for our patients.
The study researchers noted, and I agree, that the continued use of pain medication during and after addiction treatment indicates that too many patients did not receive a multimodal, integrated treatment plan for their addiction or concurrent chronic pain or co-occurring mental illness, which approximately 50-65% of those with Substance Use Disorder (SUD) have.
Dr. Alexander, the lead author of the study noted:
“There are high rates of chronic pain among patients receiving opioid agonist therapy, and thus concomitant use of buprenorphine and other opioids may be justified clinically. This is especially true as the absence of pain management among patients with opioid use disorders may result in problematic behaviors such as illicit drug use and misuse of other prescription medications.”
Addicts are quick to discover the probabilities of attaining a “high” from just about any drug they come across. Buprenorphine, while not commonly abused or sold on the streets, can be used to get high or to ease the pangs of withdrawal when heroin and other opioids are scarce.
The efficacy of treatment for SUD, regardless of the drug, is largely dependent upon non-medical factors. Yes, monitoring is important, but only if the potential for losing something one values is at stake. Surrendering, which cannot be described in medical or psychological language, is the single most important factor in determining recovery. Adjunctive treatments such as Suboxone, Methadone, N.A., A.A., CBT, yoga, meditation, diet and exercise can help a highly motivated individual. When treatment is individualized and a bond of trust is established between a counselor and patient, good and even improbable things happen, and lives are restored.
MATs are not a replacement for the traditional foundations of treatment and recovery. At best, they can provide a specific need for a specific patient. They are not for everyone. When people ask me what the elements of success are in treatment, I often start with long-term. If a person has been abusing and addicted for years, it is difficult to imagine treatment in weeks. But, as a shortcut to what works, I tell them the 3 M’s: treatment that is high-dose, intense multimodal, multidisciplinary and multifaceted, staffed by dedicated professionals who are experienced and really do care about the patients.
Suboxone and the similar medications that will be developed are inherently not good or bad and certainly don’t work for every opioid addict. But I am thankful we have them. I believe they have saved thousands of lives. The real trick of successful treatment is to know your patients and collaborate with him or her in developing a plan that gives them the best shot at recovery.