Have you ever wondered why the majority of drug rehabs and 12 step programs are dead set against maintenance drugs like Methadone and Suboxone? Even though I was on maintenance drugs for almost fifteen years and suffered because of the stigma attached I never really thought about why. Recently I came across a post on the web, posted by another recovery advocate.
It was posted on Overdose Awareness Day and I had seen countless posts and pictures of people that shouldn’t be gone. Young people who didn’t get the chance to find recovery. I used for twenty years, these kids were lucky if they made it two years. There is a big difference in my story and most of those who lost their lives to opioid addiction. I was on either Suboxone or Methadone for fifteen years and because of that, I never graduated to heroin.
I didn’t go to twelve step meetings and all the years I was on methadone I used other substances, that is my experience, but I lived. I am here to write this blog, and without a doubt, if I hadn’t taken that path I would have found heroin and more than likely I would be dead.
So if Suboxone and Methadone work so well, which they do, why are they so hated? Why do many drug rehabs and addiction treatment centers steer people away from these treatments? Why isn’t everyone with opioid addiction taking advantage of the single most successful treatment available today?
If you haven’t looked into putting someone into treatment recently you might be in for a few surprises. Did you know that it isn’t uncommon for the monthly rate to be between 15,000 and 30,000 a month for a moderate treatment center? The higher end centers can run as high as 53,000 a month. Now that price is cash pay. When the insurance is being billed they are often seeing bills for as much as 100,000 a month. So what do you get for all that money? Here are the most common therapies being used in treatment centers as we speak.
12 Step Programs
Most addiction treatment centers revolve around the 12 steps. The patients go to meeting after meeting during treatment. They also take their patients out to community 12 Step meetings several nights a week. Don’t get me wrong, 12 Step Meetings are awesome and it saves many lives, including my father. The problem is that it’s not for everyone. Some people don’t believe in a higher power, as much as people don’t want to hear that. It’s true. AA or NA works for not even 50% of the people that enter their doors. Many addiction treatment centers even take their patients out at night to actual meetings in the community at least a couple nights a week. How much does this treatment cost the addiction treatment center? ZERO, meetings are free, unless you are in the treatment of course.
How much do you think the average addiction treatment center costs if you pay cash a month? They typically run anywhere from 5k -50k a month. Enough said.
Now I love a good massage but I don’t think it’s going to keep me from chasing dope.
Doesn’t that sound fun? Especially when they show the horses running along the beach. The rider looks free don’t they. Except that isn’t reality. Really you are going to visiting horses, not taking them off by yourself down the beach. You will get to pet them, brush them, feed them some corn or an apple. You might even be asked to shovel some shit while you are there. Now don’t get me wrong I love horses. I use to ride myself but it’s strange to me that for 200 or more a session anyone believes that this is going to have anything to do with someone like me finding recovery. IF THIS WORKED I WOULDN’T BE HERE WRITING THIS.
So what do treatment centers, Big Book Thumpers, and some “advocates” think about using Suboxone and Methadone along with these other options?
It is only speculation, but one obvious answer is that residential/inpatient programs have a financial incentive to detox people and tell them that recovery without medication-assisted treatment is better. If a patient is choosing to go on methadone or Suboxone, inpatient treatment is unnecessary in the vast majority of cases., many of the staff in these programs are recovering from alcohol use disorders (AUDs). They simply do not understand that opioid use disorders (OUDs) are substantially different, though of course there are some commonalities.
Research shows that maintenance or long-term use of Suboxone (prescribed by specially certified physicians) or methadone (dispensed by special clinics that must be visited daily) not only helps individuals remain free from addiction to such opioids as prescription painkillers and heroin, it lowers death rates and prevents complications of addiction such as infections. The National Institute on Drug Abuse provides background information on these medications and how they work, as does the Substance Abuse and Mental Health Administration (SAMHSA).
Here are some of the responses I received from representatives of the rehabs I recently queried about whether they use or recommend Suboxone past the detox phase of treatment:
“Short answer, no. Suboxone is a temporary solution for a permanent problem.”
“You can get strung out on Suboxone as badly as on heroin.”
“Oh no, absolutely not. We do not discharge them on Suboxone.” When I mentioned that the scientific literature reports that people do better on maintenance Suboxone than not, I was told, “The scientific literature is false. I’ve been doing this for 20 years.”
“We’re abstinence-based. Our success is getting to the underlying issues and we can’t get to those when they’re under the influence of narcotic or other medications.”
Technically, Suboxone and methadone are opioid medications, and opioids are sometimes called narcotics. (Suboxone is a combination of buprenorphine and the medication, naloxone, which is added to decrease its potential for misuse.) Both block cravings and drug seeking – they do not produce a high or impair functioning when properly prescribed.
If someone treated with them uses an opioid such as heroin, the euphoric effects are usually dampened or suppressed.
“The notion that these are ‘narcotics’ that prevent people from doing intensive therapy when used properly is ridiculous; the converse is true.”-DR. MARK WILLENBRIN – founder, and CEO of Alltyr treatment clinic and former Director of the Division of Treatment and Recovery Research of the National Institute on Alcohol Abuse and Alcoholism at the National Institutes of Health (NIH).
Another reason is the fear of Suboxone Diversion, which means selling to other people. Studies suggest that most diversion occurs when people addicted to opioids are trying to get off them and don’t have medical access to Suboxone. It is very rare in the U.S. for people to use Suboxone in an attempt to get high.
How is Opioid Use Disorder ( OUD) different than Alcohol Use Disorder (AUDs)?
According to Dr. Saxon: Opioids affect the brain (and the body – because we have opioid receptors on our smooth muscle and our gut) differently than alcohol. So the substance effects, the intoxication, the withdrawal and the ultimate changes that occur long term in brain and body after years of exposure are bound to be different. Fully explicating the differences on a cellular or molecular level is probably a Nobel Prize-winning endeavor! But it all means that treatment needs are not just the same as for AUDs.
Is there any evidence that residential treatment is valuable for OUDs?
Dr. Saxon: There is no evidence that I know of for the standard 28-day programs, and we do know that risk of overdose is high after leaving one of those programs if patients are not continued on Suboxone or methadone. There is evidence for therapeutic communities – residential facilities where patients stay six months or longer. Of course, such programs are few and far between.
The CEO (also an addiction psychiatrist) of a company that owns a group of prominent rehabs directed me to a large Australian study, pointing out that one-year outcomes showed that medication maintenance treatment and residential treatment were equally effective. Why do we seldom hear about this study?
Dr. Saxon: One cannot generalize from Australia to the U.S. – they have a very different health care system than we do. Also, there were multiple problems with the study design – for instance, it was not randomized, and the researchers don’t even report if there were baseline differences between the groups. And all outcome data were based totally on self-report so we have no objective findings.
It’s often stressed that whenever maintenance medications are prescribed for OUDs, counseling is also important. But haven’t a number of recent studies shown that counseling confers no added benefit to the medication alone?
Dr. Saxon: Such studies relate specifically to office-based treatment with Suboxone and not to methadone maintenance. The findings are consistent in showing that outcomes were not improved when either drug counseling or cognitive-behavioral therapy were added to use of Suboxone and medical management alone. So in early treatment, it is the medication (Suboxone) that is causing the majority of change. Keep in mind that these studies only look at patients in the first several months of treatment, so we really don’t know the effects of behavioral interventions later on.
Moreover, it’s important to realize that the physicians prescribing the medication in these studies received training on how to do gold standard medical management which includes important behavioral components. So the real message is that if you have a caring and competent physician prescribing buprenorphine who asks the right questions and makes the needed suggestions, adding on more behavioral interventions may not make a huge difference. All physicians out in practice may not have these skills, though they are not difficult to learn. In methadone treatment, it is pretty clear that the medication plus standard drug counseling is better than simply giving medication alone.
What if people with OUDs have co-occurring psychiatric problems? I would think this is a big exception to the “no counseling benefit” finding, one that impacts many individuals.
Dr. Saxon: Very good point, and we don’t fully know the answer because individuals with severe psychiatric disorders are mostly screened out of such studies (many in the studies might have mild to moderate psych disorders.) However, patients with psychiatric disorders need psychotherapy and/or pharmacotherapy directed at their psychiatric disorders, not more behavioral interventions that address their addiction per se.
Some drug rehabs prefer Vivitrol to Suboxone, arguing that “head-to-head,” they are equally effective. Is this true?
Dr. Saxon: Actually, there is far more evidence supporting the efficacy of Suboxone (and methadone) than injectable naltrexone or (Vivitrol). Only one clinical trial was done in Russia (which does not permit Suboxone or methadone) supports injectable naltrexone, and that’s the one on which the Food and Drug made its decision to approve Vivitrol for OUDs. Right now, an ongoing study funded by the National Drug Abuse Treatment Clinical Trials Network is comparing the effectiveness of Suboxone versus Vivitrol for OUDs. Using naltrexone does require withdrawal off opioids for about a week before starting it, so it is more complicated in that way than using the other maintenance medications. However, if someone can make it through the withdrawal and wants to try Vivitrol, I wouldn’t have any qualms about it but would monitor the person carefully and be quick to switch to Suboxone if the person isn’t doing well. (The risk of overdose may be higher with naltrexone than with Suboxone or methadone if clients drop out or stop medications, but it’s a risk with any of the medications, and all patients should be warned.)
The CEO of the drug rehabs defended not using Suboxone at their “abstinence-based facilities,” by saying that their patients will be going to AA and NA in the community and that 12-step programs don’t see Suboxone and methadone users as abstinent, even though the medical world does. He said, “We don’t control how the recovery community sees the world. So our big focus has been on Vivitrol.”
Dr. Saxon: So their reasoning is that the AA groups are not following the actual precepts and stated policy of AA, which is to accept people who are on medications prescribed by physicians? And the rehab program is not doing the medically correct thing so as to make their patients fit into AA groups that are running AA incorrectly and judging people? They should be out there trying to get AA groups to practice AA the right way. However, if they can get Vivitrol to work, wonderful, I’m all for it.
How do costs compare between the various forms of maintenance treatment, and how likely is insurance to cover them?
Dr. Saxon: Methadone costs between $300-400 per month, which includes medication, medication dispensing, medical evaluation, counseling, and urine testing. Suboxone medication cost would be about $300-400 per month retail. Physician and counseling fees would be additional. Vivitrol is about $1000 per dose with one dose per month. Physician and counseling fees would be additional. Medicaid covers all these treatments in many states but exact coverage varies from state to state. Private insurance often covers them (variations from policy to policy, obviously), but what I hear from physicians in private practice is that it is a huge hassle to get prior authorization at times.*
*Costs for primary care treatment [initial phase] at the adult residential facilities I checked into ranged from 5,000 to about $55,000 for a 28- to a 30-day stay.
Dr. Saxon: I agree. I will have a commentary coming out in the journal Addiction this year, which makes the very same point. We need to improve our retention rates dramatically. However, saying that one treatment is suboptimal does not mean the other treatment (rehab) is necessarily better.
Twelve Step Meetings, aside from treatment centers have in my opinion interpreted the Big Book in a way that Bill W. and Dr. Bob didn’t intend. Of course, I could be wrong. I just cannot imagine the Dr. Bob would be ok with people stopping their psych meds, that end up committing suicide or all the people that don’t use Suboxone or Methadone due to the stigma. So many of those people end up dead because of an overdose. They would not want that.
Let me also just say that I am not against rehab. I have just met so many families whose loved ones have gone through drug rehab many times and continue to use opioids. drug rehab alone probably works for some, but when it doesn’t, we need to be quick to try medication.
I am also not saying everyone needs these meds. I just want people to have choices, we are all different. We learn differently and we recover differently.
Dead people don’t recover…ever…let’s keep them alive and not beat them up more in the process.
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Written by Recovery Advocate for Kill the Heroin Epidemic Nationwide™, Heroin News, and the National Alliance of Addiction Treatment Centers (NAATC)
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