Please Post Research on the Success Rates of Various Forms of Treatment

[Jabberwocky]

There has been a lot of discussion about success rates when it comes to the common treatments out there for substance use disorder. There is also a LOT of confusion out there, largely due to people mistaking anecdote as evidence.

Please remember, there are a number of substance specific use disorders out there (you don't treat alcohol use disorder like you treat amphetamine use disorder). Particular substance use disorders are also labeled according to their acuity, mild, moderate or severe. Likewise, a treatment that might work well for someone with a severe opioid use disorder might not work well for someone with mild opioid use disorder.

Here is a recent example of something that has come up on the topic of success rates:

almost all of the people i used to get loaded with are dead now. so are most of the
people i got sober with. that's a fact. harm reduction proponents cite the 12 step
communities 90% failure rate. they are being far too optimistic. it's more like a
98~99% failure rate. that doesn't mean it doesn't work. it does mean that the
way it is approached by most people doesn't seem to work out well.

i haven't seen numbers on harm reduction strategies that are encouraging,
either. most of them haven't been collecting data long enough for definitive
conclusions.

Here are some topics that seem to come up regularly when people refer to what they believe the success rates are from personal experience or second hand awareness of the research:

In the case of this particular post, I find a kind of tragic irony operating. When the user refers to "the way it is approached by most people," they are implicitly blaming the patients receiving treatment for the failure of their treatment. The logic that goes like "98% of treatment attempts using an abstinence-only based modality; the treatment failed these patients; the cause of these treatment failures is the patient not engaging in the treatment correctly" seems highly problematic to me. I mean, who do we care about succeeding more: the patient or the treatment ideology/provider?

I mean, we label (well more and more of society are beginning to label) addiction as a disease (although few seem to understand the particular of this or give it much thought). Treatment for substance use disorder is covered by medical insurance (this is probably the most significant). The most largest amounts of money folks spend on substance use treatment goes to pay for exploitatively expensive inpatient style abstinence only rehab and 12 step based programs. I don't think anyone could argue that abstinence based treatment isn't technically a form of medical treatment, however impoverished its application might be.

Wether or not it's particularly "good" (useful) medicine, it is being promoted as such by these kinds of treatment providers (and politicians, proponents of prohibition and drug war ideologues). I don't think anyone in their right mind would argue that 12 step methodolgy is a form of medical treatment, but rightly or wrongly it is being provided as such. Insurance is paying for it to be employed as part of medical treatment each and every day.

In what other field or form of medicine is a treatment failure (to be specifics, I mean a failure of the treatment provided to resolve the issue being treated) blamed on the patient? I have yet to find one. This issue, of blaming the patient, is fairly common to all types of substance use disorder treatment. After all, stigma is so insidious when it comes to drug use, substance use disorder and addiction. More so, I'd argue, than the conditions themselves. A fatal OD might have extinguished someone's life, but living in a mental prison or having a mind colonized by self hatred and stigma isn't all that much better.

I feel strongly that collecting and discussing the actual research we are always alluding to, on the efficacy of various forms of treatment, would be helpful in promoting an awareness that it isn't the patient's fault the treatment they were provided didn't work, that fault has little to do with the situation. Instead, it would promote the understand that treatment failures are the result of pairing an particular person with particular challenges with an inappropriate form of treatment (and that triage probably wasn't performed very well, as is super common among abstinence based treatment providers where patient mean paychecks).

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Part of what I'd also like to do is disseminate some myths surrounding harm reduction programs. Methadone is actually probably the most studied of all forms of treatment for any kind of addiction. Other public health oriented harm reduction projects like needle exchange have been studied all over the world for decades. There is so much we know about harm reduction programs, yet the attitudes of many people in the recovery community about harm reduction reflects little about the actual harm reduction community.

Needle exchanges have proven highly effective over the last twenty to thirty years at drastically reducing the spread of communicable disease (and not just for drug injectors or crack smokers, but their friends, sexual partners, family, etc). There is also very strong evidence to suggest that public health organizations such as needle exchanges that operate according to the principles of harm reduction move clients towards the direction of abstinence. There is rarely not a decease in drug use over time when users are engaged with something like a needle exchange.

Furthermore, methadone has been used to treat substance use disorder since the 60's. The research surrounding treatments involving methadone is very robust, much more so than research surrounding 12 step mythology. It squarely indicated the vastly increased efficacy of methadone based ORT programs over abstinence based programs to treat severe opioid use disorder.

Something that must be highlighted is that ORT programs like methadone clinics are in fact abstinence based programs. They utilize methadone, in this particular case, to treat a condition. The success of this treatment is measured in days where no drugs or non-prescribed medications were used, where prescribed medications where used as prescribed. Where patients make appointments and follow through with their treatment plan. Where they don't relapse.

That sounds a lot like abstinence only based treatments, at least in terms of what they'd like to see from their patients. The difference between them is that one uses a particular medication to treat a particular condition (methadone; severe opioid use disorder) that abstinence only providers tend to view as an illegitimate form of medicine (despite the decades of research demonstrating otherwise).

And, of course, that you'll generally get kicked out of abstinence only treatment if the condition being treated flairs up (in this case, when someone diagnosed with substance use disorder uses whatever drugs they're struggling with). I never understood how it helped a patient who had relapsed during treatment to discharge them from treatment. I get how it might be better for others in the facility in a way, but that totally disregards what is best for the individual patient who has relapsed.

That is highly unethical. Again, where else in medicine is continued treatment is refused by the provider when the condition being treated relapses?

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So, to the point of this thread, what research into success rates for various forms of substance use disorder treatment do you know of?

Abstinence only based rehab, 12 step programs, outpatient based program, inpatient based program, non-12 step programs, various approach to individual therapy like CBT/DBT/motivational interviewing, confrontational based approaches, ORT programs, non-opioid related MAT, whatever. Anything in a peer reviewed journal that deals with the issue of how effective certain treatments are.

Let get some reference for the 4-10% success rate for abstinence treatment, and the ~50% (or something, I forget off the top of my head) success rate of ORT programs!

 

[simco]

A great source on the (meager) success of 12-step programs is Lance Dodes' book, The Sober Truth: Debunking the Bad Science Behind Twelve Step Programs and the Rehab Industry (Beacon Press, 2015).

Dodes cites his own research and many other clinical studies to bolster his claim that AA/NA have a success rate of 5-10% (not much above the rate of spontaneous remission).

As someone who is fairly involved with NA in my own recovery, I feel that this book is really important. It's crucial that we don't overstate the general effectiveness of treatments that happened to have worked for us individually.

 

[Jabberwocky]

He was the first addiction kinda author I ever encountered (The Heart of Addiction). Not a bad first IMHO Thanks simco, I'll definitely check his book out.

 

[simco]

I liked The Heart of Addiction, too. A lot of the arguments he makes there are similar to what he talks about in The Sober Truth. Personally, I was disappointed by his more instructive book (Breaking Addiction). But his basic premise--treating addiction has to address the underlying emotional causes--always struck me as spot on.

 

[herbavore]

... But his basic premise--treating addiction has to address the underlying emotional causes--always struck me as spot on.

And here is where it gets complicated. I think anyone who has experienced addiction themselves or experienced up close and second-hand the addiction of a loved one understands on some level the need to "treat" the underlying causes. Ok, so now we move into another realm where the outcomes are dismal, the methods and resultant data both political (job protection, need to justify and guard belief systems) and $$ driven; I am talking about the world of mental health "treatment". Just as much of an industry, just as full of limiting and outdated beliefs and just as entrenched in the cultural psyche.8( Read Robert Whitaker's Anatomy of an Epidemic for more information.

So what does a person do? Take ownership. Of everything. When you do that, roads and pathways and doors appear. It takes years to know yourself, endless trial and error to heal yourself, but there is always a clear starting point and that is when you decide to embark upon it.

 

[Jabberwocky]

I think, for many people, "treating the underlying causes" is related to more than mental illness. Of course, what like half the people receiving substance use disorder treatment also experience some form of mental illness, but mental illness itself has underlying causes (poverty is a great example). Address those and you go a long way to addressing the conditions that make the mental health and substance use disorder so problematic. Of course, mental health treatments aren't any more advances than SUD treatments these days, but the field does offer a lot of treatment options that seem to work very well for some people.

In a certain sense, I think what you are talking about, taking ownership, is indeed important - it can be very liberating. But there are also lots of issues that keep drug users in bondage. Plus, the whole idea of taking ownership is something that is regularly ruthlessly exploited by poorly trained drug counselors, dogmatic 12 step members and scared family members. Things get really shitty really fast when something is presented as taking ownership but is just some confrontational tough love bullshit (and this happens all. the. time.).

In my experience, as long as they can stay alive, folks figure things out for themselves. They figure out how to take ownership of their lives as well as stand up for what their own particular needs are, as drug users and human beings. The most options and space I give people to figure their own stuff out, the more effective they seem at doing so - whatever that means to them.

Perhaps I should ask: What do you mean exactly by taking ownership? Like, what is the process you're envisioning. I have a feeling it doesn't involve tough love or confrontation.

I hear something like what you wrote and my mind immediately goes to some kind of inventory process. That was not exactly my experienced. As soon as I found people who actually heard what I was saying, and were able to deeply listen to me as I express myself and things I find important, it because very easy to live a healthier, freer life.

 

[cj]

I've been looking for statistics. Outside of methadone the studies are just not there. Its c almost like they don't want to be studied. Like if you had a program you really believed worked would you not want a double blind study to prove it?

 

[Kawasaki88]

It is completely normal to feel strong cravings when tapering; however methadone is proven to be a less successful program than suboxone for that very reason. I would speak to your doctor about your options and do not be afraid to tell them exactly how you feel. A lot of the time, they are able to help ease the pain a lot more than you may think. Clinics will be a lot more insensitive than going to your normal primary care doctor believe it or not in most cases.

 

[simco]

It is completely normal to feel strong cravings when tapering; however methadone is proven to be a less successful program than suboxone for that very reason. I would speak to your doctor about your options and do not be afraid to tell them exactly how you feel. A lot of the time, they are able to help ease the pain a lot more than you may think. Clinics will be a lot more insensitive than going to your normal primary care doctor believe it or not in most cases.

What do you mean by methadone being less successful than suboxone? Maybe in terms of tapering (I honestly don't know). But in terms of maintenance, there's quite a lot of evidence that for people suffering from severe opioid use disorder, methadone is much better at controlling cravings and preventing relapse.

 

[Jabberwocky]

It is completely normal to feel strong cravings when tapering; however methadone is proven to be a less successful program than suboxone for that very reason. I would speak to your doctor about your options and do not be afraid to tell them exactly how you feel. A lot of the time, they are able to help ease the pain a lot more than you may think. Clinics will be a lot more insensitive than going to your normal primary care doctor believe it or not in most cases.

Actually tapering off methadone doesn't necessarily involve cravings more than tapering off buprenorphine (in my experience it was about the same, if not actually easier - I'd prefer dealing with the end of a proper methadone taper any day over buprenorphine). I don't know where you're getting the idea in your post.

Now, I think a lot (by no means most) private doctors are easier to deal with than public clinics, but the highly structured and regulated nature of the clinic also can be hugely supportive. Frustrating, sure, but helpful too.

 

[Kawasaki88]

Many patients that were used in scientific tests, like the one cited below to see which one was better showed they are both effective; however, Suboxone keeps users from a relapse at a higher rate. I did not mean to state that the cravings would be less, I should have said it is a safer avenue to go.

"All patients had been prescribed either methadone or Suboxone for maintenance for 6months prior to intake. Results showed that when controlling for a number of patient-level covariates, both methadone and Suboxone significantly reduced current users' days of heroin use between the 90days prior to intake and at the 8-month follow-up, with Suboxone yielding a significantly larger magnitude reduction in heroin use days than methadone."(http://www.sciencedirect.com/science/article/pii/S0740547212000803)

 

[Kawasaki88]

Methadone has stopped being prescribed in a lot of areas due to it's inferior results as cited from one article I listed below. Either way, you will have cravings, but suboxone is proven to prevent you from relapsing better than Methadone is. I have seen this both personally, read it, and spoken to professionals about it.

 

[Jabberwocky]

That sounds more like marketing than actual peer reviewed research evidence. I'll have to look into that article, but what comes off the top of my head is that methadone is tailored to patient populations who are much more likely to relapse than buprenorphine (it is far easier to get on buprenorphine than methadone, and a lot of folks tend to try buprenorphine prior to trying methadone, before their habit has gotten really bad).

A statement such as "Suboxone is proven to prevent you from relapsing better than Methadone is" is a statement I'm very uncomfortable with. Methadone is, in literally every way, more effective at controlling cravings than buprenorphine is, regardless of whether patients taking methadone are more likely to lapse during treatment than buprenorphine patients are (that says more about the patients themselves than the efficacy of the medication to me - you have to remember that populations taking buprenorphine and populations taking methadon tend to be rather different).

There research out there is pretty miserable on this stuff, comparing methadone to buprenorphine I mean. Very impoverished I mean. Now, if you could find a study that controlled for everything other than whether someone is taking methadone vs buprenorphine vs no ORT, which I can pretty much guarantee isn't out there, you probably find very similar efficacy rates.

And for the record, the availability of methadone has nothing to do with research. If it was, you'd see far more providers out there. What limits its availability is primarily the strict regulations placed on using it as ORT (there are not comparable restrictions on patients taking it for pain) and the stigma surrounding methadone and methadone patients. Most small cities simply don't want to allow business operating that they perceive as festering sores of addiction, crime and general depravity (a representation that has nothing to do with methadone clinics and everything to do with personal bias and misunderstanding, and sometimes politics).

After reading over the abstract, it seems you simply misinterpreted the study, drawing conclusions it doesn't actually support:

"Methadone and Suboxone were highly and equally effective for preventing relapse to regular heroin use, with all but 3 of 37 (91.9%) patients who were abstinent at intake reporting past 90-day point prevalence heroin abstinence at the 8-month follow-up. Overall, prescribing methadone or Suboxone for eight continuous months was highly effective for initiating abstinence from heroin use, and for converting short-term abstinence to long-term abstinence. However, the study design, which was based on a relatively small sample size and was not able randomise patients to medication and so could not control for the effects of potential prognostic factors inherent within each patient group, means that these conclusions can only be made tentatively. These positive but preliminary indications of the comparative efficacy of methadone and Suboxone for treating opiate dependence now require replication in a well-powered, randomised controlled trial."

So at best a statement such as "buprenorphine prevents relapse better than methadone" (apart from being rather unscientific itself) simply cannot be made according to the authors of the study you've cited.

P.s. I don't mean to be a dick, I'm just a bit rushed and writing in a matter of fact tone. I would very much love and welcome more discussion surrounding ANY research related to the efficacy of ANY treatment options out there. THANK YOU for bringing this into the discussion!

I'll have to find a thread I started some time ago on this topic and move our posts here into it, hopefully to stimulate further discussions.

 

[Kawasaki88]

Both can be an effective way to treat opioid dependency; however, it is also proven that Methadone is number one for lethal overdoses and misuse out of it's class, and is not as effective as Subuxone.


https://rightpathaddictioncenters.com/methadone-or-buprenorphine/

 

[Jabberwocky]

I'm sorry but you are being a little ridiculous. You're using information on a rehab's website as evidence to support your point? Come on...

I don't even know where to begin with the shit on that website. There are some kernels of truth there, but it paints a picture that is more about promotion than science or peer reviewed evidence.

I don't even know what the statement "methadone is number one for lethal overdoses and misuse out of its class" means, and I've already dealt with your "it's not effective as Suboxone" bit. In reality it isn't better or worse - it has a different application.

Of course there are more lethal ODs associated with methadone than buprenorphine. The latter has a ceiling effect, the former does not. The latter is a mixed agonist/antagonist, the former is not. I can most definitely state however that buprenorphine is just as prone to "misuse" as methadone is. There more than enough personal anecdotes on this site to demonstrate reality.

When used as prescribed, both drugs essentially have the same safety profile, with buprenorphine perhaps a bit less lending itself to misuse (then again, the control on methadone are so strict misuse isn't nearly as easy as with buprenorphine).

 

[Jabberwocky]

Sigh, you haven't provided anything actually stating methadone is less "effective" than methadone (welcome to the poverty of research about addiction...).

To point out, methadone isn't "more addictive" than buprenorphine. If taking methadone as ORT is addiction, so too is using buprenorphine as ORT (both will maintain dependency to opioids, but not addiction when used as prescribed).

And frankly there isn't anything wrong with staying on any ORT medication for an indefinite amount of time. Most people seem to get the most out of around 6mo-2yrs, but there isn't anything wrong with staying on it far longer if one is benefiting from it. That goes for both methadone and buprenorphine.

There is this common misconception that folks on methadone are more likely to stay on it longer than buprenorphine. When they're both being used for maintenance purposes, I've encountered just as many people taking buprenorphine long term (2 or more years) as I have methadone. I have seen just as many people struggling to get off or maintain proper buprenorphine use as I have methadone. They're very comparable medications, dependencies and experiences detoxing from. More in common than not, in other words.

It's just as easy to get "addicted" to buprenorphine as it is methadone, and it's just as easy to use them for long periods of time. Dependence or these medication isn't necessarily a bad thing however, just as staying on them longer term isn't.

What a lot of people also don't realize is that most opioids can be used as effective maintenance drugs. It's just that (for some good reasons) medicine and politics surrounding addiction have prioritized these two drugs for its use. However, in more enlightened places, you also have other options such as heroin assisted treatment, which have proven quite successful.

That is probably why I have a problem with such as broad statement as buprenorphine (or methadone) is better than the other one. It simply isn't accurate. Some people will benefit mor from buprenorphine than methadone. Other methadone over buprenorphine. Others still pharmaceutical heroin or hydromorphone over buprenorphine or methadone.

Just like there isn't a panecea when it comes to treating addiction, there isn't one "best" ORT medication. There is no magic bullet, not in any of this.

 

[Kawasaki88]

That is a good point, but you would be implying now that the availability is why Methadone is abused more? They also do not have the same safety profile. The data for Methadone simply states that it is used for patients with a high dependency and it specifically states that Buprenorphine has a good safety profile. It appears to me there is one clear choice. Below is the chart on both:

[h=3]Buprenorphine[/h]	[h=3]Methadone[/h]	[h=3]Heroin[/h]
Partial agonist	Full agonist	Full agonist
Long half-life (24 to 60 hours)	Long half-life (8 to 59 hours)	Short half-life
Ceiling effect; good safety profile	No ceiling effect (useful in patients dependent on high doses of opioids)	No ceiling effect

 

[Jabberwocky]

Thanks to the mixed agonist and ceiling effect buprenorphine probably does have a better overall safety profile than methadone (with a tolerance however, both medications can easily kill an opioid naive individual).

It depends what you mean by "abuse". If abuse means not using it under a doctors care or as prescribed, then I think yes the greater availability of BUPRENORPHINE (depends on the location, but in most places I've been buprenorphine is far more available on the black market than methadone is).

From what I've seen, both methadone and buprenorphine as "abused" (I prefer "misused") at similar rates and in similar ways mirroring how they're used as ORT and detoxification medications. Where methadone is more available and buprenorphine less available, you'll probably see more methadone misuse. In places where there is more buprenorphine available (which is now mos American cities), you'll see more buprenorphine misuse than methadone.

A big reason you don't see as much methadone in many cases is because it is more highly regulated (by far) and controlled than buprenorphine is. Most of the methadone you see sold on the streeets is coming from pain related prescriptions, as opposed to most buprenorphine which is almost entirely coming from substance use disorder treatment related prescriptions.

Now, for a variety of reasons I tend to suggest people try buprenorphine before methadone. Methadone is just a bigger commitment in many ways, and going into it half cocked can lead to more problems Thant it solves (that can be said of buprenorphine as well though). But really it has more with the work and effort one puts into getting healthy AND the circumstances of their particular life leading them to seek out ORT, when it comes to determining which medication is preferable.

There really isn't a single standard for everyone all the time with these meds. Given the situation, one will work better than the other (and that has a lot to do with the circumstances they're prescribed/taken under too). At one point buprenorphine may be the better choice for someone, while at another point in their life methadone may become the better choice.

And also it might be worthwhile to keep in mind there are a lot of qualities that makes methadone preferable to buprenorphine. The full agonist is far more useful at managing/eliminating cravings than the less satisfying effects of buprenorphine. And when one is using methadone as ORT, that will allow them to use buprenorphine to transition off - which makes for a very comfortable transition.

Increasing supervised access to both these medications would undeniably be a good thing in terms of public health. I feel like I'm being a tad pendantic with you, and for that I apologize (using my phone's browser doesn't help). It's just that I have over a decade or experience dealing with the committed study of opioid use, opioid use disorder and the treatment of opioid use disorder. It's a fascinating subject, but there is soooooo much misunderstanding and stigma surrounding it out there from a century of Prohibitionist and drug war propaganda it can be difficult to actually discuss rationally.

 

[Kawasaki88]

By abuse, I mean a doctor prescribes substances all the time that harm individuals. Often times, due to what you previously stated when you said"marketing." Looking at the facts, neither are great. Your going to be addicted and dependent on yet another substance; however, one will be a little more realistic for you to discontinue.

 

[Jabberwocky]

So from reading your posts it's become clear you have a very limited understanding of opioid use disorder. If you're interested in facts, ORT is far more effective at helping folks with accurately diagnosed severe opioid use disorder disengage from a lifestyle of addiction, end their reliance on substance use generally speaking than abstinence based approaches. We've now got almost 60 years of evidence to support this.

Dependency isn't the issue. It's the harms associated with the drug use and it's consequence that are problematic. Opioid use isn't inherently harmful, although it can easily become so. Given the particular draconian climate opioid users (particularly injection and recreational users) face, most of the harms surrounding opioid use today can be traced directly to our drug policy, the war on drugs and the history surrounding all of that (pick up a copy of Chasing the Scream).

I found it far easier to taper and detox from methadone than I did Buprenorphine. The primary reason was that I'd been able to use the medication to get to a point I my development where I was far more able and capable of doing so. Was methadone responsible for that growth? Only indirectly. Methadone gave me the stability I didn't have on buprenorphine to focus entirely on learning skills to better care for myself and navigate life. And that is what ended up saving me.

Both are just as easy to use properly and taper off as the other. The issue is that most people (and doctors), such as yourself, have such a limited understanding of opioid use disorder and it's treatment that they don't know what they'll need to do in order to successfully detox or whatever. When they do, in many cases they cannot get access to the support they need to do so. This all has nothing to do with these medications themselves, and everything to do with the poverty of how out public policy deals with drug use, of substance use disorder treatment, and the related science and medicine out there.

We are so off topic I will definitely need to move our posts, but it has been a great (if at times rather frustrating) discussion with you!