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PROMETA as been demonstrated to be the sham we all knew it was.

Keith Humphreys offers a brief history of the “treatment” and some lessons:

1. …when the next wonder drug for addiction comes along (and it will), we must not yield to our powerful collective desire to believe before we have hard evidence of effectiveness from disinterested, respected sources. The simpler, faster and more miraculous-seeming the cure, the greater should be our skepticism.
2. There is a worrisome vulnerability in the US FDA’s new drug approval process. As was the case with another would-be ‘miracle cure’—ultra-rapid opiate-detoxification—a manufacturer was able to market an untested treatment protocol to addicted patients because the components of the treatment protocol had been previously FDA-approved for the treatment of other disorders.
3. Independent scientific research on addiction is essential for public health and safety.

If only it was easier to know what research and perspectives are independent and disinterested.

Related articles

• Join Together withdraws PROMETA article
• More on Prometa
• End of the Line for Prometa? (addiction-dirkh.blogspot.com)
• Anti-depressant Confusion
• Pain, Meds and Money
• a curious lack of skepticism
• Dr. Drew accepted pharma money?
• Top Posts of 2011 #1 – The Suboxone “Solution”

What’s so compelling is that this is a tough on crime speech by a rising and influential Republican governor who resume includes having been a prosecutor and he calls for diversion, compassion and treatment for addicts:

At the same time, let us reclaim the lives of those drug offenders who have not committed a violent crime. By investing time and money in drug treatment – in an in-house, secure facility – rather than putting them in prison.

Experience has shown that treating non-violent drug offenders is two-thirds less expensive than housing them in prison. And more importantly – as long as they have not violently victimized society – everyone deserves a second chance, because no life is disposable.

I am not satisfied to have this as merely a pilot project; I am calling for a transformation of the way we deal with drug abuse and incarceration in every corner of New Jersey.

So today I ask this Legislature and the Chief Justice to join me in this commitment that no life is disposable.

I propose mandatory treatment for every non-violent offender with a drug abuse problem in New Jersey, not just a select few. It will send a clear message to those who have fallen victim to the disease of drug abuse – we want to help you, not throw you away. We will require you to get treatment. Your life has value. Every one of God’s creations can be redeemed. Everyone deserves a second chance.

Salam summarizes:

he … made the case that nonviolent drug offenders should be given treatment rather than imprisoned because (1) it is cost-effective, (2) it is decent and humane, and (3) it recognizes that we can’t afford to waste human potential.

Reducing drinking in these cases is a very good thing.

To me, there are several important questions but the first might be, “then what?”

Do we pat ourselves on the back that they are housed and drinking less? Mission accomplished? Or, do we view this gradual change as a start and continue to move them toward recovery?

If we’re talking about the latter, I have no quarrel with a program like this, in principle. (I say, in principle, because, in the context of scarce resources, my bias will probably be that funds would be better spent on improving treatment access and services.)

The study and coverage of it makes me bristle a bit because it responds to and refutes an “enabling hypothesis” that a housing first approach will increase an alcoholic’s drinking. This seems like a bit of a straw man.

Maybe I’m an outlier among people who are concerned about these kinds of programs, but my concerns are:

1. That this kind of program does nothing to address the individual’s alcoholism. (Not that it would make it worse.)
2. That it’s a palliative response to a treatable condition.

The study does address #1 to an extent. My response is that drink counting doesn’t tell you a whole lot about alcoholism, particularly with very severe cases. Addiction’s impact is so multidimensional to the individual and the loss of  control extends so far beyond drinking that it’s dot as though a 10% reduction in drinking equals a 10% improvement. Several analogies come to mind, for one, if your’re in chronic and severe pain and the pain is reduced by 10%, is that success? Does it equate to a 10% improvement in well being? Not necessarily. Sometimes, small improvements in a symptom are accompanied by disappointment and depression that this might be as good at is gets. The person may still be disabled. The pain may still be severe enough to interfere with sleep, relationships, other pleasures or participating in activities that are associated with wellness.

Again, I welcome improvement, IF it’s accompanied by an effort to continue moving in the direction of recovery.

My concern about the palliate approach is that it’s based on the assumption that these people can’t get well. This assumption often rests on other assumptions:

• That they’ve had access to treatment before and have not responded.
• That they don’t want recovery.
• That treatment is too expensive.

The problems with these assumptions are that:

• They probably never got treatment of the appropriate duration and intensity.
• Context is important in wanting recovery. Does the person see living proof that recovery is possible? Does the person work with helpers that express hope and optimism about their capacity to recover? Is help of adequate intensity and duration available on-demand?
• Treatment and recovery support doesn’t have to be expensive.
  • Arguments based on costs and savings are arguments within the economic monoculture and deserve re-examination. (Hospice is probably much cheaper than cancer treatment too, does that make it the right thing to do?)

There’s a way in which this is two things at once. An aggressive attempt to meet the basic needs of some very vulnerable community members, AND a form of abandonment by lowing expectations and offering no hope for recovery and wellness. (There was no reference to recovery  or gradual movement in the direction of abstinence in the article.)

At about 7:00, he says:

So a German researcher named Rainer Hambrecht looked at this with about 100 cardiac patients He got the group to exercise, and by that I mean 20 minutes a day in an exercise bicycle and once a week a 60 minute aerobics class, and the other half got the high tech stent and just did their normal activity, and after one year 88% of the exercise group were event free, compared to 70% of the people who got a Stent. So both worked, but I find it sort of incredible that the low tech made a bigger difference and you have to remember that the Stent just fixes one part of the heart.

Earlier, he outlined the diverse benefits of physical activity in various populations, including:

• [in knee arthritis patients, it] reduced rates of pain and disability by 47%
• reduced progression to dementia and Alzheimer’s by around 50%
• reduced progression to frank diabetes by 58%
• 41% reduction on the risk of hip fracture
• reduced anxiety by 48%
• 23% lower risk of death
• number one treatment of fatigue
• shown again and again to improve qualty of life

This got me thinking about whether12 step recovery is to addiction what exercise is to heart disease.

Preventing heart attacks is a very good thing. That stents exist and are readily available is a very good thing. This sounds like a very strange thing to wonder, but would we be better off it cardiac care was a little less medicalized? If there was a little more parity in research and resources invested in helping people be more physically active? I know that there are some efforts in this direction, but is the medical system missing the boat?

In the same way we have interventions (like medications) that can prevent overdose and reduce drug use. But, these offer none of the other benefits. Further, the damage done by addiction is often pretty global—physical, emotional, social, familial, spiritual, occupational, educational, etc. So…an intervention narrowly focused on drug use is, at best, a start on the path to wellness and recovery.

Of course we can’t make cardiac patients exercise and we shouldn’t withhold care to patients who do not exercise or give them second class care. But, maybe, the medical system should be more focused on “recovery” rather than just harm reduction?

The addiction treatment system did a lousy with people who didn’t engage in our version of exercise, we didn’t do a good job supporting it beyond a period of a few weeks or months, we sometimes used some dubious and even harmful methods to get people to do it. (We’re not alone in this. Medical history is full of dubious and harmful methods.) But…there’s been a lot of improvement, a lot of success and it offers global benefits that go well beyond abstinence or reduced drug use. So…why are so many people in a hurry to abandon and dismantle this system?

“Choose [your memories] carefully. Memories are all we end up with … You’ll have a thousand pasts and no future.” –The Secret Behind Their Eyes (film)

forget about the sunshine by whatmegsaid

A friend shared this On Point episode with me and made a connection between it and resentments.

This matter of appropriate, helpful, deliberate forgetting is very fascinating.

We’ve talked before about role of the brain’s memory circuits. I’ve also been very interested in the similarities between PTSD and addiction. Both are characterized by intrusive, powerful, multi-sensory, involuntary memories.

The On Point episode discusses that the capacity this helpful forgetting relies on executive function which we’ve discussed is impaired AND depleted.

So…addicts may have limited capacity for this kind of helpful forgetting. Maybe this explains and supports 12 step recovery’s emphasis on letting go of resentments.

Further, the idea in the quote above may help explain the emphasis on gratitude and the power of gratitude lists. Aren’t gratitude lists really an attempt to choose what to remember?

The Fix has a provocative article on the growing use of buprenorphine maintenance. Over the last several years we’ve watched long-term maintenance become the norm and it has been a growing concern at Dawn Farm, particularly as we’ve had growing numbers of people misusing the drug and others seeking help getting detoxed from buprenorphine.

She presents the dilemma for addicts this way:

Should they take buprenorphine, or “bupe,” long term mainly to avoid cravings—and the junkie lifestyle—or heal their bodies by detoxing and staying clean, which is harder and, in certain ways, riskier? Weighing the costs and benefits of each approach is a very personal, even existential, matter, and science can offer only limited advice, since there are no studies of long-term use of buprenorphine in former opiate addicts. We’re pretty much on our own.

Addicts are not alone in wrestling this this dilemma. It has also been a difficult subject within our own community of professional helpers and it’s not going away. While this has been on the minds of many practitioners and addicts, I’ve never seen an article question buprenorphine maintenance.

I have a strong point of view on the subject and believe that the following principles should inform any services for addicts: that drug-free recovery is possible for most opiate addicts and; that drug free treatment of the appropriate duration and intensity should be made available to every every opiate addict.

Also, more than ever, I’m very comfortable with addicts being given their choice of treatment options. I’m convinced most will migrate toward full, drug-free recovery. Addicts hate their addiction and want to be free of it.

So, with my bias made plain, a few important questions leap out to me:

• Is is necessary?
• Is it helpful?
• Is it harmful?
• Is it compatible with other treatments and paths to recovery?

Let’s take these one at a time. Please, keep in mind that, while I have an opinion on the subject, I’m trying to unpack all of this and muddle through it.

Is it necessary?

One group of people is consistently offered care of appropriate intensity and duration with the expectation that they can achieve full recovery—their outcomes are consistently stellar. That group is health professionals. This tells me, that in a broad sense, it’s not necessary.

One of the arguments is that addicts don’t want drug-free recovery:

“The people who try abstinence, they’re like the starfish on the beach. There aren’t many of them.”

As I said before, I think most will migrate toward drug-free recovery. There are two big conditions on this belief. First, that addicts are offered access to quality recovery support and treatment services of adequate intensity and duration. The second is that the helpers they encounter must consistently communicate hope for full recovery.

Overdose prevention also falls into this category:

In France, where the drug was in use for a decade prior to FDA approval, fatal overdoses of heroin and other opiates fell by 80%.

This is a frequently cited argument for buprenorphine maintenance. It’s compelling if you believe that stable recovery is unlikely—we don’t based treatment decisions for health professionals on an expectation of relapse and overdose.

Is it helpful?

I’ll let one of the advocates in the article make this case:

[Junig's] advocacy of bupe maintenance is based on “the least worst” logic. Most of his patients who have tried to detox off, he says, return to legal or illegal drug use. Worst of all, some OD. “I want addiction to be treated like every other chronic fatal illness,” he says. “We put people through treatment, they clean up, they come out looking good, we all congratulate ourselves—and then six months later, the patient dies,” he says. “And no one cares about this. There’s no review of what we might have done better, the way there would be if the patient died of a heart attack, for example.”

When patients take buprenorphine, he says, they quit stealing and lying, they become employable. “Especially if they’re over 40, they do well,” he says. “It’s like they’re taking their blood-pressure pill.”

We’re not seeing suboxone maintenance patients achieving stable recovery. It’s easy to counter that there’s a selection bias in our experience and I’m sure there’s a lot of truth to that, though our outpatient program typically has clients on suboxone maintenance.

Is it harmful?

One critic on the neurobiology of buprenorphine:

Switching from one opiate (heroin, methadone) to another (bupe) does not “heal” the neurological aspect of addiction, which is characterized in part by the phenomenon of tolerance: as long as exogenous opiods are taken, the body decreases its production of endorphins and increases the number of receptors.

…But Scanlan is a fierce opponent of such long-term bupe use. “There’s no way your brain chemistry can heal while on buprenorphine,” he says. “You’re continuing to give someone a narcotic.”

…He has noticed that at long-term doses of even 2 mg, bupe can block almost all of a person’s emotions. “They say to me after they’re off for a while, ‘Wow, I’m really having a full range of feelings,’” he says.

I share this concern and find it very credible, though I just don’t believe we know enough yet about the neurobiology of recovery to speak definitively on the matter.

And, while advocates argue that the drug offers freedom, the author offers her experience of it as diminishing but extending her bondage:

…of course I asked my doctor if I could stay on Suboxone forever. He had no more maintenance slots left. And then, two or three weeks in, still at 6 mg—I was dragging the taper out as long as I could, because I Felt So Well—the affair went sour. My appetites gradually diminished. My voice clogged up again. My attention was constantly dragged back to how I was feeling—and whether it was time for my next dose.

It took me six more weeks to get off Suboxone, and it was during that time I started going to meetings. I probably could have tapered more quickly, but what slowed my descent onto the tarmac was simple: I was afraid of having nothing left to take. I had taken painkillers every morning, to cope, for so many years. Now, fortunately, I don’t have to.

Note that she didn’t start going to meetings until she was close to discontinuing the medication. Is this a good argument against the use of a drug to manage a chronic illness? I don’t know. Large numbers of people on statins or blood pressure medications could control their symptoms with diet and exercise and improve the quality of their lives and global health. Are they less likely to make changes in diet and exercise because their can control some symptoms and reduce risks with a pill? Probably. Should doctors restrict access to these drugs because of this? Probably not. Should doctors settle for for this? I think not.

Is it compatible with other treatments and paths to recovery?

An obvious question is, “Why not bupe AND tradition treatment and recovery support?” I’ve already touched on this and I’m going to take the long way back around.

I’m convinced that the driving force behind much of this is not a conviction that buprenorphine maintenance is the ideal approach. Rather, it’s driven by a resignation to it being the best many practitioners can do—we can’t offer enough monitoring, we can’t offer more than short-term residential or inpatient, we can’t offer community based recovery support services, we can’t offer outpatient treatment of sufficient duration and intensity, we can’t address all of the client’s other problems that will interfere with recovery, etc.

I have two reactions to this. First, I understand the real world constraints most practitioners function within. I can respect choosing a second best option when the best is not available. However, I expect informed consent (If you were a doctor we’d send you to residential treatment and provide and advocacy for access to the best option. I don’t see this happening.

Second, when one thinks about addiction as a chronic illness, we have historically failed on one front and succeeded on another. We failed to conceptualize addiction as a chronic illness and sold treatment in an acute care model with time-limited doses of treatment provided with the expectation of permanent full recovery. We (Actually, mutual aid groups, rather than treatment, deserve the credit for this.) succeeded in creating long-term disease management support for the behavior and lifestyle changes needed to maintain recovery. What practitioner working with cardiac, obesity or type II diabetes patients wouldn’t envy our free, vibrant communities of support that help initiate and maintain these behavior and lifestyle changes over decades? They’d be crazy not to envy this. We’re not starting in the same place as practitioners trying to encourage diet and exercise. We’ve enjoyed considerable success for decades.

This migration to buprenorphine maintenance has not been one of adding a pharmacological tool to this historical strength. Rather it’s been a migration away from this strength. (Read the comments on the article and it becomes clear that neglect of these patients needs and preferences is not a rare experience.)

Clearly, this doesn’t have to be an either/or decision, but practitioners are telling us that buprenorphine clients don’t want the rest of the “recovery lifestyle”. Why is that? Is there something about the drug that reduces motivation to do so? Does it interfere with the experience of the benefits of the lifestyle?

Again, why this push when we have a model that works very, very well?

A solution is to offer clients their choice of treatments and combinations. I know I’ll take what the doctor’s having.

History

Dawn Farm has had a longstanding commitment to helping opiate addicts, especially IV heroin addicts. But withdrawal from opiates produces symptoms that clearly make it more difficult for opiate addicts to join the recovering community. So even though our treatment approach had a history of proven success, we were excited about the FDA approval of buprenorphine (Suboxone, Subutex) in 2002. Any drug that reduced the suffering associated with opiate withdrawal without significant mood altering effects was cause for celebration.

Today, Dawn Farm still believes that buprenorphine can be a very helpful detoxification tool. But over the last several years we’ve watched long-term buprenorphine maintenance become a treatment norm around us, apparently following a tradition that began with methadone maintenance. We are profoundly troubled by this trend.

Dawn Farm has been especially concerned as we’ve observed three disturbing developments:

1. Young (18-22 year old) first-time treatment seekers with early stage addictions are being placed on buprenorphine and maintained on it indefinitely. This is routinely done without any meaningful discussion of treatment options.
2. Growing numbers of our incoming clients routinely misused buprenorphine, including Suboxone, the preparation that is promoted as having no misuse value.
3. Growing numbers of clients contact us seeking help to detoxify from (not with) buprenorphine.

Dawn Farm has always opposed most forms of drug maintenance treatment. We believe they reflect a view that opiate addicts can’t achieve lasting, drug-free recovery. We are concerned that the changes we’ve seen in how buprenorphine is prescribed are based upon that view.

We know better. For decades, we have seen IV opiate addicts achieve lasting, abstinent recovery. The recovering community in our area includes hundreds of successful, drug-free opiate addicts—many of them in their early 20s. Our experience indicates that drug-free recovery is possible for any addict—when provided with high quality treatment of adequate intensity and duration.

All of Dawn Farm’s sites display a quote on the wall by the esteemed addiction physician George Vaillant:

“If you want to treat an illness that has no easy cure,
first of all, treat them with hope.”

We believe that hope consists in an expectation of recovery—an expectation borne out by our experience.

So as we consider the subject of buprenorphine maintenance, we ask four basic questions:

        Is it necessary for achieving stable recovery?

        Is it helpful to achieving stable recovery?

        Is it harmful to the goal of achieving stable recovery?

        Is it compatible with other proven treatments and paths to recovery?

1. Is it necessary?

We frequently hear the argument that buprenorphine maintenance is necessary for a variety of reasons. Let’s address a few of them.

“Other treatments for opiate addiction often fail.”

Other treatments do frequently fail. Addiction is a chronic illness and, like other chronic illnesses, there is no cure. We can, however, minimize relapses my providing treatment of adequate intensity and duration. Recovery for opiate addicts is an achievable goal.

It is worth noting that there is one specific group of opiate addicts that is consistently offered care of appropriate intensity and duration—with the expectation that they can actually achieve full drug-free recovery. This group’s outcomes are consistently stellar, with 5 year relapse rates below 25%. This group is health professionals.[1] Doctors and nurses are not treated with drug maintenance.[2]

“Addicts don’t want drug-free recovery.”

Our experience tells us that this is a myth—and a reflection of helpers’ low expectations. Dawn Farm believes that active addicts hate their lives—and that most will migrate toward drug-free recovery contingent on two important conditions: access to quality recovery support and treatment services, and helpers who consistently communicate hope for full recovery.

“Opiate replacement is needed for overdose prevention.”

This is a frequently cited argument for buprenorphine maintenance. It’s compelling if you believe that stable recovery is unlikely—a premise we know to be untrue. Treatment decisions for health professionals are not based on an expectation of relapse and overdose—and their outcomes are measurably better. The disparity in outcomes between addicted doctors and “street addicts” comes perilously close to raising potent questions about class prejudice in the treatment field.

2. Is it helpful to achieving stable recovery?

We have a number of clients who take medications. For individuals suffering from co-occurring clinical depression or other disorders, medications can greatly assist our clients as they navigate early recovery. While we are conservative about psychotropic medications, we clearly see their benefit in individual cases (see our position paper on Mood Disorders).

However, we simply are not seeing buprenorphine maintenance patients achieving stable recovery. We have a number of outpatient clients who come to us on opiate replacement therapy—we are not seeing clinical success among them.

3. Is it harmful to achieving stable recovery?

Buprenorphine works to quell withdrawal and craving for the same reason as methadone because it is recognized by opioid receptors in the brain as a potent narcotic. It is not difficult to transfer an addict’s dependency from one object to another, especially to another drug and especially when the addict is on the cusp of abstinence and extremely vulnerable.

Like methadone, buprenorphine produces a picture of stability with no withdrawal and little or no craving/pre-occupation, but it does so because it produces an “upload” effect. In fact, the person on maintenance is only as stable as the assurance of his next dose. The situation is analogous to long term methadone patients who are decreasingly capable of (or interested in) getting off the drug the longer that are on it. The longer patients are maintained on methadone, the less likely they will ever become drug free.[3] Not surprisingly, a similar pattern is becoming apparent with buprenorphine patients on “stable” maintenance.[4]

Nationally, practitioners have begun expressing concern that buprenorphine maintenance actually interferes with achieving stable recovery.

These concerns include:

• There are early indicators that buprenorphine maintenance does not allow for neurobiological healing, i.e. increasing production of the body’s own opioids and replenishing opioid receptors.[5]
• Cognitive impairment has been found in methadone and buprenorphine maintenance patients when compared to abstinent recovering opiate addicts.[6]
• Buprenorphine blunts the emotional experiences of the user, interfering with key emotional aspects of recovery, including the development of new coping skills.[7]
• Buprenorphine maintenance patients may be less motivated to engage in activities of self-care we generally associate with stable, full recovery. These include 12 step attendance and involvement, breaking ties with aspects of the addictive lifestyle, building relationships with recovering people, etc.[8]

We find these concerns credible, though we don’t believe we know enough yet about the neurobiology of recovery[9] to speak definitively on the matter.

4. Is it compatible with proven treatments and paths to recovery?

An obvious question is, “Why not buprenorphine AND traditional treatment and recovery supports?”

One big barrier is the ambivalence 12 step groups have toward opioid replacement treatment.[10] Officially, opioid replacement patients are welcome in these fellowships but are not considered to be in recovery. This leaves the opioid replacement patient in the position of hiding their use of medication if they wish to be embraced by these fellowships—a very precarious position for an aspiring member of a fellowship that advocates rigorous honesty.

We’re sadly persuaded that the driving force behind buprenorphine maintenance has little to do with any conviction that it constitutes an ideal approach. It appears, rather, to be driven by a resignation to suboptimal resources—practitioners can’t offer enough monitoring, they can’t offer more than short-term residential or inpatient treatment, they can’t offer community-based recovery support services, they can’t offer outpatient treatment of sufficient duration and intensity, they can’t address all of the client’s other problems that can interfere with recovery, etc.

We understand that practical constraints challenge most practitioners, and we can respect the necessity of choosing a second best option when the best is not available. However, in such situations we expect informed consent:

“The best treatment plan for you would include long term treatment, long term community-based recovery support and recovery monitoring for 5 years with rapid re-intervention in the event of a problem. However, this isn’t an option for you. So, ….”

The patients and families we encounter have had no such conversation.

The recovery process (i.e. treatment, mutual aid groups, community) is, at its core, a structure to support individuals long enough to go through the anxiety and distress of transferring their dependency from a drug to non-destructive, non-shaming sources of supply (human and spiritual relationships). The essential elements of this process are a very high level of structure and social support over a sustained period of time along with a sufficiently strong personal need to take the risk of going through a day without drugs.

Buprenorphine, like methadone, quells the need for a substitute. You can make participation in therapy or 12 step meetings a condition for continued access to the drugs but the motivation to participate is pursuit of the drug, not a sense of having found a sufficient substitute. The individual’s progress is dependent upon the next dose rather than on trusting, functional relationships with human beings.

Mutual aid groups, rather than treatment, actually deserve the credit for creating long-term support for the behavior and lifestyle changes necessary to maintain recovery. Considered in this context, what practitioner working with cardiac, obesity or Type II diabetes patients wouldn’t envy a no-cost, vibrant community of support to help initiate and maintain behavior and lifestyle changes over decades? In this respect, the addiction treatment field has a long head start over practitioners treating other chronic conditions and has enjoyed considerable success for decades. Consequently, we believe that the move toward buprenorphine maintenance has not added an effective tool to the historical strength of the recovering community—rather it has wandered away from it.

Further, many treatment providers have historically failed to effectively promote the concept of addiction as a chronic illness. Instead they have sold treatment under an acute care model, with time-limited doses of treatment, all the while paradoxically promoting an image of permanent, full recovery unsupported by their outcomes.

We believe that the most stable adjustment to recovery comes with access to a source of supplies that is limitless, non-confining and available everywhere. In this respect, the limitations of opiate replacement therapy are obvious.

Clearly, buprenorphine doesn’t have to be an either/or decision, but practitioners are telling us that buprenorphine clients don’t want the rest of the “recovery lifestyle.” Why is that? Is there something about the drug that reduces motivation? Does it interfere with experiencing the benefits of sobriety? We routinely see men and women who begin the process of recovery as hopeless addicts, only to find that they have the ability to function without a drug. They can become free in the truest sense of the word—limited only by their own hopes, dreams and willingness to continue to grow.

In summary, we are not persuaded that opiate replacement therapy is either necessary or fundamentally helpful for opiate addicts seeking recovery. We see clear examples of real harm to stable recovery caused by buprenorphine. And we continue to encounter ways in which this maintenance approach is incompatible with interventions that produce meaningful long-term abstinence. We are especially troubled by the fact that buprenorphine is routinely offered to IV heroin addicts but not to impaired physicians.

Why would we move toward buprenorphine maintenance—when we have a model[11] that works?

Charles F. Gehrke, MD, FACP, FASAM; Martin Gleespen, MD
James Balmer; Jason Schwartz, LMSW, ACSW, CAADC, CCS

• Drug policy should aim to promote the public good by improving individual and public health, neighbourhood safety, and community and family cohesion, and by reducing crime.
• The effectiveness of most drug supply control policies is unknown because little assessment has been done, and very little evidence exists for the effectiveness of alternative development programmes in source countries.
• Supply controls can result in higher drug prices, which can reduce drug initiation and use but these changes can be difficult to maintain.
• Wide-scale arrests and imprisonments have restricted effectiveness, but drug testing of individuals under criminal justice supervision, accompanied by specific, immediate, and brief sentences (eg, overnight), produce substantial reductions in drug use and offending.
• Prescription regimens minimise but do not eliminate non-medical use of psychoactive prescription drugs. Prescription monitoring systems can reduce inappropriate prescribing.
• Screening and brief intervention programmes have, on average, only small effects, but can be widely applied and are probably cost-effective.
• The collective value of school, family, and community prevention programmes is appraised differently by different stakeholders.
• The provision of opiate substitution therapy for addicted individuals has strong evidence of effectiveness, although poor quality of provision reduces benefit. Peer-based self-help organisations are strongly championed and widely available, but have been poorly researched until the past two decades.
• Health and social services for drug users covering a range of treatments, including needle and syringe exchange programmes, improve drug users’ health and benefit the broader community by reducing transmission of and mortality due to infectious disease.

It’s good stuff. I particularly like its willingness to give credit where credit is due. For example, supply control can help but the benefits are often unstable and have a lot of unintended consequences. I also like the affirmation of the diversity of perspectives on the benefits of policies.

Not surprisingly, the only thing that grates me is the pushing of opiate substitution. (They weigh in a little harder in the body of the paper.) I’ve got no objection to saying it should be part of the service menu, but when they argue that it’s got the strongest evidence base, shouldn’t we ask why that is? What drives the research agenda? Who decides what to research? Who decides what outcomes are important? What are their assumptions? What are their values? Who benefits from the research agenda?

I don’t fear substitution being part of the service menu, but I fear it becoming the standard of care. I fear it setting the bar unacceptably low and creating a reflexive loop that reinforces the assumptions of researchers and treatment providers and traps addicts in a state of permanent disability and dependence upon treatment providers who believe they’re incapable of recovery.

Would the researchers and doctors recommend this treatment to a loved one? To a colleague? (Hint, they definitely don’t recommend it to colleagues. And, it’s not too expensive for the rest of us.)