Medications like methadone and buprenorphine have become the gold standard for treating opioid use disorder (OUD). But many people with OUD still receive abstinence-based treatment or no treatment at all for the chronic disorder.
And people with OUD who receive abstinence-only treatment are more likely to die than people who receive no treatment at all, according to a new study published in the Journal of Drug and Alcohol Dependence.
The study, led by Yale researchers, analyzed data from 965 people who died from an opioid-involved overdose in 2017. While previous research has compared abstinence-only treatment with medication-based treatments, this study is the first to compare the two paths with no treatment at all.
The results determined that medications for OUD significantly reduced the risk of death — by 38% for methadone and 34% for buprenorphine.
People who received treatment that did not utilize medications (abstinence-based therapy) were 1.2 to 1.7 times more likely to die than those who were exposed to no treatment at all.
One of the study’s researchers, Robert Heimer, told Behavioral Health Business that while many found the study’s results surprising, the findings were aligned with his expectations.
“We’ve known for a century that abstinence doesn’t work,” Heimer, a professor of epidemiology and pharmacology at Yale University, said. “That’s not to say that abstinence is inevitably a failure. It works for some people and many of the people for whom it works become passionate advocates for abstinence. The problem is that they are in the vast minority, but they are the ones who survive.”
Heimer suggests that abstinence-only treatment is more dangerous than no treatment at all because patients lose tolerance to drugs they previously took at high doses, resulting in far deadlier relapses.
Removing stigma
The barrier keeping more patients from receiving medication for OUD, Heimer said, is stigma.
“The ones for whom medication works don’t talk about it because medications remain stigmatized,” he said. “Buprenorphine and methadone are still considered by many people, even by drug users themselves, and certainly by many in their families, as just substituting one drug for another. It is a ridiculous notion when you understand the biology of addiction.”
Because OUD is a chronic condition, Heimer says that it requires continuous management. He prefers the term “remission” rather than “recovery” for this reason.
“The drugs themselves, methadone and buprenorphine, you could take for a lifetime,” he said. “They don’t have kidney or liver toxicity. They don’t cause cardiovascular disease, COPD or infectious disease complications. They’re incredibly safe drugs. The fact that they are underused is a failure of the medical system to act based on available evidence.”
Some treatment plans recommend tapering off medications for OUD, advice that may be informed by stigma and may have fatal consequences.
“I can’t tell you how many people I’ve met who lost loved ones because their provider told them they had to taper off suboxone to remain in a treatment facility or sober living – or who were discouraged from maintaining suboxone by their mental health therapist or drug counselor,” Stephanie Strong, founder and CEO of substance use disorder (SUD) treatment provider Boulder Care, told BHB in a statement.
Portland, Oregon-based Boulder is an outpatient SUD treatment provider offering telehealth services and prescription medicines, including buprenorphine and naltrexone. The company raised $36 million in 2022 in its series B funding round.
“Stigma and misperceptions about addiction helped create this status quo: the notion that addiction should be punished, and people struggling should repent,” Strong said. “But funding streams perpetuate it, as programs that do not offer MOUD are less regulated, less administratively burdensome, and more profitable.”
The results of this study are compelling enough to inspire direct change in how the medical field treats OUD.
“This is cause for alarm,” Stephen Martin, Boulder’s medical director, told BHB in a statement. “When we learned leeches and bleeding hurt patients, we eventually stopped the practices and sought helpful treatments. We need the same urgency to make buprenorphine and methadone the actual, practiced standard of care and to remove funding from models that harm patients.”
Changing the funding paradigm
The study’s authors said they hope the findings will impact how states will direct opioid settlement funds. One of the ways Heimer said he hopes to see funding directed is to make methadone more accessible.
“We right now have extensive data that suggests that methadone is a better drug than buprenorphine,” he said. “The retention rates, in clinical trials at least, seem to suggest that it’s a little better. The problem with methadone is the delivery system.”
FDA regulations currently limit methadone distribution to a special “closed system” in which only hospital pharmacies and physicians registered with both the FDA and DEA can dispense the drug, according to the National Institutes of Health. Distribution of the drug is further limited by many state governments and, in some cases, also by counties and municipalities.
Heimer also hopes to see access to buprenorphine improve, in part through training providers to talk with patients about medications.
“We have to find ways to get more people willing to prescribe buprenorphine at therapeutically appropriate doses, which in the fentanyl era is probably 16 to 24 and maybe even 32 milligrams a day,” Heimer said. “We have to stop treatment programs from thinking that getting people to stop their medications is an appropriate form of therapy. That should only be a very carefully considered conversation between a knowledgeable prescriber and a patient to alert the patient to the downsides of terminating their medication.”
Strong suggests state and federal funding for abstinence-based programs should be greatly reduced.
“Today, we see millions of dollars going to recovery programs that deny patients who use suboxone and promote outdated, stigmatizing practices,” she said. “We believe this is cause for alarm, both because we are not going to fix our nation’s pressing societal problems this way, and because we’re spending precious public resources that actually make things worse.”
Others suggest that abstinence-based treatment still has its place.
Cooper Zelnick, Groups Recover Together’s chief revenue officer, said that while medications are the most effective method for reducing deaths relating to OUD, other treatment methods should still be available.
Groups Recover Together is an OUD treatment provider that leverages buprenorphine and group therapy to promote members’ recovery through in-person or virtual care models.
“While we strongly believe in MOUDs (medications for opioid use disorder) for treating OUD, we also believe that there is a place for inpatient and/or abstinence-based care within the continuum, and we wish to emphasize that the answer, especially given ongoing access gaps, is not to reduce utilization of any one modality, but rather to increase coordination across the continuum,” Zelnick told BHB in an email.
Heimer suggests that more people in remission from OUD who take medication for the disorder should come forward to help reduce stigma.
“We need those people to be more vocal about what’s worked for them and why it’s worked for them,” he said. “The data are so clear that the medications are superior to abstinence-based treatment. That’s not a question. What we need are the anecdotes and stories from people who succeeded. I tell my students that while the plural of anecdote is not data, the plural of anecdote is often policy.”