You know what would help put an end to the debate? A protocol and procedures for a successful transition off maintenance for those patients who would prefer not to remain dependent.

sub-vs-nosub…that is the question.”

I came across an Internet debate on the relative merits of opioid maintenance versus opioid-free treatment. Not the first such debate I’ve encountered, and certain not to be the last.

One side argues that if addiction is indeed a chronic disorder along the lines of diabetes, then the use of ongoing medication should count as a legitimate form of recovery, the way it would with insulin used by a Type 1 diabetic. That seems reasonable enough.

The other side, however, counters that because the addict is still completely dependent on high doses of opioids — the drug that brought him to treatment in the first place — that can’t be considered equivalent to recovery without opioids, even if other drug use has been curtailed.

That also seem pretty reasonable.

Both sides tend to focus on the flaws in one another’s approach as a way of demonstrating the superiority of their own. Advocates of maintenance point to low abstinence rates for drug-free programs. Their opponents argue that all maintenance does is make their addiction legal.

It would be nice if we had a third option. One where a patient could reasonably expect to be on methadone or buprenorphine for a period, until stable, and then taper off without an expected return to heroin. But the evidence so far suggests that doesn’t often happen. Opioid maintenance, for most at least, seems to be an endpoint, not a beginning.

I heard from one psychiatrist who claimed considerable success tapering people slowly off buprenorphine and onto monthly naltrexone injections. The patient’s still dependent on the naltrexone, of course, but since it’s not an opioid, objections are few. The doc admits to focusing only on the highly motivated patient, and there are never all that many of those around.

You know what would help put an end to the debate? A protocol for a successful transition off maintenance for those patients who would prefer not to remain dependent. Something that would reassure the public that we hadn’t just “settled for” permanent maintenance, sometimes called ‘parking’.

I’ve been looking for signs of an effort by scientists to find one. So far, I haven’t seen much.

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3 Comments »

Thanks to both Rachel and Alan for their comments. I have several friends who are former OMT clients who complain they received very little support in their efforts to taper off. There’s a tendency to blame it on profit motive by the program but I think it’s more complex. Philosophy, ideology, call it what you like.

I’ll never forget a lunch I had with a methadone nursing supervisor for DC. Also there was our marketing director, a former methadone client. Our staff member shared her bad experiences and the nurse dismissed them as evidence that she’d been on the wrong dose. “But I was on all different doses,” our marketer exclaimed. “Obvious not the right dose,” the nurse replied, patting her hand.

Comment by Scott McMillin — December 2, 2014 @ 6:01 pm

Great topic! I was on Suboxone for a little over a year, then swapped over to Methadone (to reduce adverse side effects) & have been on it for a little over a year as well.
When I first started Opiate Replacement Therapy, I knew very little about it. I started for a myriad of (somewhat contradictory) reasons; I couldn’t keep using drugs the way I was using & didn’t want to die as a result, I also felt like it was a legal way for me to continue my addiction, but at the same time thinking it would be the answer to all my problems & I could finally quit everything once & for all.
Soon after starting ORT, all of my (illicit) drug use ceased (with the exception of a handful of small relapses), but I reverted back to drinking – heavily.
Just over 2 years on & a lot has changed for me. I’ve been attending NA/AA etc. & am now drug & alcohol free (except for methadone – and I ID as such at meetings), and I’m progressively reducing off methadone, with the hopes of being completely clean once I’m done.
Before going to meetings, I had no real plan; not many options & little hope.
I personally feel that being on ORT has changed my life. I don’t believe I would have come this far without it, so I am very grateful for it. However, it’s not something I want to be on forever & quite frankly, I wish I could stop right now.
I know that the question of “To maintain or not to maintain” is a difficult question, and it’s very much a case by case/person by person answer, however I don’t believe it should be so black & white.
I wish there was more support for the “3rd” option, as I’ve found it incredibly hard to find (if at all). If not for a few lucky turns in my journey, I might not have had the willpower or determination to continue with the 3rd option. I believe that if there was more support, that was widely accepted, more of us would have a chance to do better & beat this disease.
Addiction, recovery, health, medication, medical services etc, is never black & white. The treatment shouldn’t be either.

Comment by Rachel Even — November 27, 2014 @ 9:13 pm

I think that you have brought out something that is a major oversight in addiction treatment. While in the beginning drugs might give a better chance of success, it is truly substituting one drug for another. If the scientific community would just create protocols to follow for the weaning off of the prescribed drugs there could be a game plan in place. While addiction treatment is anything but simple, it seems that creating this protocol should not be too difficult.

Comment by Alan — November 24, 2014 @ 10:51 am

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