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Hands Holding PillsBy Jim Seckman, MAC, CACII, CCS
CEO, MARR, Inc.

First of all, before you form an opinion based on the title of the article, please let me state as clearly as possible, that the use of buprenorphine (suboxone) is not really my issue here. If we back up for a moment, I can absolutely affirm that the values of programs who prescribe buprenorphine and those of abstinence-based programs are exactly the same: We all want to save lives. That really is the bottom line. I agree there is evidence that shows that the use of buprenorphine allows many individuals to get off heroin and participate in treatment. That evidence is not my issue either.

The issue for me is the unqualified endorsement of the use of buprenorphine as the only viable treatment for opioid use disorder to the exclusion of other treatment modalities that are also proven to be effective.

The opiate epidemic has intensified fears of families and communities, and with good reason. In a reaction to the demands of communities, there has been a movement from legislators and the medical community towards medication-assisted treatment (MAT) that focuses almost exclusively on the use of buprenorphine, which is itself an opioid based narcotic. This has also led to treatment becoming more individualized and away from a longer length of stay and the therapeutic community model.

And, what is even more disturbing, is that many of the most vocal proponents of MAT completely ignore approved medications that are extremely effective, but not opioid based: Naltrexone and Vivitrol (extended release Naltrexone). These medications negate the effects of opiates in the brain and have been shown to reduce cravings, thus allowing clients to participate fully in treatment without any opioid based medications.

MARR has just completed an 8-year study that demonstrates the efficacy of an abstinence-based model that works with clients who are suffering from opioid use disorder. We found that as we modified our program structure to meet the needs of these clients, we began to see higher retention rates and successful completion rates that consistently surpass the national averages for long-term treatment programs.

MARR Outcomes Study

I have no doubt that evidence shows that buprenorphine works. However, it is unfortunate and misleading, to the public at large and to helping professionals, to ignore existing and emerging evidence that shows that abstinence-based programs, particularly those that are long-term, based in the therapeutic community model, and who use Naltrexone and Vivitrol as support medications, are effective as well.

We are all working very hard to save lives and address this terrible epidemic. It is clear that we need a variety of modalities in our treatment approaches in order to be effective across a broad spectrum of clientele. Please don’t be intimidated by the strong, singularly focused voices out there right now. Let your voice be heard about the practices and modalities that you know work for your population!


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6 Comments

  • Robert W. Ford says:

    My initial thought is how strange it is that an argument needs to be made in favor of an abstinence-based model. I will offer three thoughts about the now widespread use of programs relying on suboxone to “treat” opioid addicts.
    1) The fundamental weakness of using suboxone is the same fundamental weakness we saw with methadone. Using a drug to treat drug addiction.
    People who establish long-term recovery do so because they develop the inner and outer resources which enable them to cope with acute and post-acute withdrawal and, beyond that, to cope with life. They work a recovery program. They have an active spiritual life. They build a recovery network, mostly through a 12-step fellowship.
    Most people who rely on a chemical crutch don’t do that. When, sooner or later, the chemical crutch goes away, they have inadequate coping skills (and little or no recovery) so they return to active addiction. IN my experience as a counselor, this is as true with suboxone “treatment” as it is with methadone “treatment.”.
    2) I have worked as a counselor for many years. Mostly in treatment programs, including the therapeutic community model. Most recently, I have worked in sober living programs. There, I saw the transition from mostly meth addicts to mostly opioid addicts. Numerous of our residents were prescribed suboxone. Specifically, the suboxone film. A lot of those who took the suboxone film found ways to cook it and shoot it up. I cannot say with certainty they got high taking it that way — never tried it myself — but those who did that usually did it more than once. (By that time, they were generally getting discharged.) The pharmaceutical company which makes suboxone will probably deny that opioid addicts can use it in this way, but they do.
    3) The efficacy of using suboxone as a treatment modality should be challenged, not simply accepted just because government and big business are pushing it. Today in America most research on prescription drugs is financed by giant pharmaceutical companies. I believe that, given their emphasis on maximizing profits, they expect to get what they pay for when they finance these projects. Results favorable to their bottom line. I would insist on seeing the results of research done that was in no way financed by the company standing to profit from favorable findings.
    I would also be skeptical of research done by the government. Nowadays, regulatory agencies such as the FDA are themselves regulated by the industry they are supposed to regulate. Most of their top people come from the industry, Others, who have worked their way up in the government, can find very lucrative jobs in the industry if they learn to play ball. These are facts which can be verified without too much effort.
    As for research done or sponsored by SAMHSA or NIH, I would check out who was involved and who paid. There is a good chance you will find a pharmaceutical company presence in that research. When billions in profits are on the line, these companies will do almost anything, and the federal government is almost hopelessly compromised.
    Bottom line: abstinence-based treatment is the only legitimate treatment. Treating opioid addicts with opioids is like putting alcoholics n a program where we give them only a couple of beers a day.

    • Marc Burrows says:

      Robert, I have worked as a counselor in abstinence based treatment and medication based treatment for the last 5 years. I can say with absolute certainty that more people died in abstinence treatment than did on medication. Also, medication gives someone a chance to get his or her life back or build a new one whereas abstinence treatment gives someone 28 days of repair before being released back into the wild where relapse is likely. MAT definitely has its problems, and we have a lot to learn. Just like other treatment modalities, it’s not perfect and it has pros and cons. We need to be more standardized across the board and weed out the doctors who are incompetent in this field.

      • Julie Hansen says:

        Marc,
        The point of the article is that long term (90 + days), abstinence-based treatment is effective. I fully agree that 28 days is insufficient and may even be insufficient with MAT because there are so many underlying issues that are not/cannot be addressed in so short a time.

  • Jim Seckman says:

    Robert,
    Thank you so much for your comments! Yes, it’s time that we got our voice out there!
    Jim

  • Randy C says:

    I agree with the sentiments expressed by this article and the opinion following it. My problem with suboxone treatment is that it only treats the outward unmanageability of addiction. The underlying emotional issues are likely seldom addressed because they lie dormant as the client medicates their addiction with another substance as well as that the counseling that accompanies MAT treatment is often seen as an obligatory nuisance to a lot of clients who are often primarily motivated by a fear of being sick.

    From my perspective, long term suboxone maintenance is like telling someone with a broken leg that they’ll never be able to walk again due to the broken leg because they’re unable to heal, so “here’s a wheelchair that we will show you how to live a full functional life in. ” While abstinence based treatment basically states “your leg is broken, it will be painful, but we will help you learn how to walk again, so you want need that wheelchair, and maybe someday you can run that marathon you always dreamed of, if you so desire. “

  • Jim Seckman says:

    Randy,

    I like the broken leg analogy. Yes, there is an assumption within the MAT community that abstinence is not possible for opioid addicted persons (Dole 1988) so a replacement drug is necessary to help them function. Of course, that may be true for some people, but it’s misleading to generalize that assumption. Thank you for your comment.

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