By Sarah E. Wakeman, MD, FASAM
May 3, 2017
In a 2016 research letter to the New England Journal of Medicine, Dr. Sigmon and colleagues describe the results of a randomized pilot study of interim buprenorphine dosing for individuals with opioid use disorder.1 Interim buprenorphine dosing means offering medication alone to people on a waiting list to get into a buprenorphine treatment program, which generally involves medication plus counseling. This study randomized patients to either staying on the waiting list or getting just the buprenorphine administered at home by an automated and locked pill dispenser. The results were compelling. All of the participants who remained on the waiting list continued to use illicit opioids. In contrast, the majority of those treated with buprenorphine stopped using opioids completely, with abstinence rates of 88%, 84%, and 68% at 4, 8, and 12 weeks (P<0.001 for all comparisons).
Given the requirement to offer counseling with buprenorphine treatment and the emphasis placed on psychosocial interventions in the treatment of addiction, these results may seem surprising. It is important to highlight that Sigmon’s findings build on a robust base of evidence which calls into question counseling requirements. It turns out that effective counseling for people getting buprenorphine doesn't have to come from a therapist; another trial found that medication management visits with the prescribing physician providing counseling in the office were as effective as additional psychosocial interventions.2 Previous research has also shown that interim methadone treatment significantly reduces drug use and improves clinical outcomes.3 In fact, no rigorous study has ever been able to show that the addition of psychosocial services to opioid agonist therapy alone improves outcomes in the treatment of opioid use disorder.4,5 So why then do we continue to limit access to these lifesaving medication treatments? In a thought-provoking piece about the history of addiction treatment in the US, Dr. Walter Ling, a renowned physician-scientist, reflects on our approach to limiting access to methadone and buprenorphine.6
From the very beginning our policy has been: Addicts are sick, they need help; but they also sin and must suffer a little. So we built treatment programs and put up barriers making it difficult for patients to get into treatment. The justification was to prove their motivation... We as a society basically … think addicts should just get off drugs and by strenuously hauling up on their own bootstraps and should stay off no matter what. Policymakers and some clinicians continue to promote detoxification as ‘treatment,’ even though detoxification does nothing to help people stay off drugs.
If today is like any other day in the US, 144 people will die in the next 24 hours from a lethal overdose including 91 from an opioid overdose.7 The World Health Organization estimates that treatment with methadone or buprenorphine reduces an individual’s risk of overdose death by nearly 90%.8 And yet, less than half of the 2.2 million Americans with opioid use disorder are receiving treatment, with waiting lists for medications for addiction treatment the norm rather than the exception. In Vermont alone there are 500 people on a waiting list to access buprenorphine.9 Waiting lists are not merely an inconvenience, they are quite literally deadly. A study of people on a waiting list for methadone treatment found the risk of death to be ten-fold higher than in those on the medication.10 A recent news article made personal the devastating impact waiting lists can have by sharing the story of Taylor Wilson, a young woman who waited 41 days to get buprenorphine treatment and died from an overdose hours before the clinic called to finally offer her an appointment.
Voltaire’s famous quote, “Don’t let perfect be the enemy of the good,” is frequently referenced in medicine as a reminder to not let lofty ambitions prevent important progress and innovation. Yes, opioid addiction is a complex disease ideally treated with comprehensive care. Yet the evidence is clear that medications alone can be highly effective. Deaths due to opioid use and addiction now kill more Americans than car accidents or firearms. Why limit access to these medications which can substantially reduce opioid use and overdose death? As Ling describes, stigma and belief have historically influenced treatment models for addiction to a far greater degree than science. In the midst of an epidemic we can no longer afford this unscientific approach. We have the tools to end the crisis, so the question now becomes whether we have the will.
Opioid Use Disorder Education Program
Learn more about the latest medical and psychosocial treatment options, best practices, and legal guidelines for identifying and treating OUD in a free online program produced by Harvard Medical School.
The Opioid Use Disorder Education Program (OUDEP) is comprised of three CE/CME courses produced by Harvard Medical School with scientific contributions from The National Institute on Drug Abuse (NIDA). These courses are intended for nurses, nurse practitioners, physician assistants, physicians, and other health care providers collaborating to treat patients with substance use disorders.
1. Sigmon SC, Ochalek TA, Meyer AC et al. Interim Buprenorphine vs. Waiting List for Opioid Dependence. N Engl J Med. 2016 Dec 22;375(25):2504-2505.
2. Fiellin DA, Barry DT, Sullivan LE, et al. A randomized trial of cognitive behavioral therapy in primary care-based buprenorphine. Am J Med. 2013 Jan;126(1):74.e11-7.
3. Schwartz RP, Kelly SM, O’Grady KE, Gandhi D, Jaffe JH. Randomized trial of standard methadone treatment compared to initiating methadone without counseling: 12-month findings. Addiction. 2012 May;107(5):943-52.
4. Schwartz RP. When Added to Opioid Agonist Treatment, Psychosocial Interventions do not Further Reduce the Use of Illicit Opioids: A Comment on Dugosh et al. J Addict Med. 2016 Jul-Aug;10(4):283-5
5. Ling W, Hillhouse M, Ang A, Jenkins J, Fahey J. Comparison of behavioral treatment conditions in buprenorphine maintenance. Addiction. 2013 Oct;108(10):1788-98.
6. Ling, W. A Perspective on Opioid Pharmacotherapy: Where We Are and How We Got Here. J Neuroimmune Pharmacol (2016) 11:394–400
7. Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. MMWR Morb Mortal Wkly Rep 2016;65:1445–1452.
8. United Nations Office on Drugs and Crime/World Health organization (UNODC/WHO). Opioid Overdose: preventing and reducing opioid overdose mortality. 2013. Retrieved from https://www.unodc.org/docs/treatment/overdose.pdf Accessed on April 13, 2017.
10. Peles E, Schreiber S, Adelson M. Opiate-dependent patients on a waiting list for methadone maintenance treatment are at high risk for mortality until treatment entry. J Addict Med. 2013 May-Jun;7(3):177-82.
Dr. Sarah Wakeman is medical director of the Substance Use Disorder Initiative and the Addiction Consult Team at Massachusetts General Hospital (MGH), co-chair of the Mass General Opioid Task Force, and clinical lead for the Partners Healthcare Substance Use Disorder Initiative. Dr. Wakeman is also an assistant professor in medicine at Harvard Medical School. Twitter