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> In the U.K., researchers looked at data from more than 150,000 people treated for opioid addiction from 2005 to 2009 and found that those on buprenorphine or methadone had half the death rate compared with those who engaged in any type of abstinence-oriented treatment.

That's some pretty scary data. Half the death rate... that's a very significant number.

> You're advocating to stay on a drug the rest of your life?

Why not? It saves lives (hello insulin). And here's a telling bit from the article:

> When patients take a stable, regular and appropriate dose, maintenance medications don’t cause impairment, and the patient can work, love and drive. In essence, what maintenance does is replace addiction — which, remember, is defined as compulsive use despite consequences — with physiological dependence, which, as noted above, is not harmful in and of itself.

Here's the link with much more info about buprenorphine: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4293937/

Certainly it would be nice to have an effective solution that didn't require daily use... but we don't. What we have is a safe drug that cuts the death rate by half.

If there were 0 people who recovered from opiate addiction without being hooked on a maintenance drug for the rest of their lives then it'd have more credence. If you give an alcoholic xanax for the rest of their life because it affects the same area of the brain but they aren't drunk anymore, are they recovered?

Not to mention, that seems like a pretty horrible and bleak outlook to make people believe they can't make a full recovery without being medicated for the rest of their life.

Again, I've known many people who have taken these drugs and a large number of them relapse bad. In fact, from what I hear the withdrawl from suboxone is 10x worse than from heroin.

It's not always about recovery, but harm reduction.

best is the enemy of better, sometimes we can only do better and best is a pipe dream. I spent most of my life so far learning this.

And sometimes better is our best. I'm on Suboxone. I'm okay with that. Harm reduction is a good thing.

If someone replaces a drug that's doing them very serious harm with a drug that doesn't do them harm, I don't see the problem.[1] I take doctor prescribed medication daily that I could live without but it significantly increases my quality of life, I don't see a difference between me and a person who is on methadone but otherwise well in life - has job, money, clothes, friends, community, etc.

[1] Xanax has a lot of problems with long term use though, so Xanax, specifically, would likely not be a good candidate.

My MIL replaced alcohol and cocaine addictions with a coffee addiction. It's been over a decade and she doesn't seem to have any significant negative outcomes with the coffee and coffee is cheap and readily available almost everywhere. From what I see, I believe the coffee is more of a psychological crutch for her - but it's not harming her.

First of all, thank you for sharing your experience. It was insightful, and I completely agree with your criticism of the article.

I would like to make a small, and perhaps somewhat pedantic comment regarding your last statement:

>In my own humble opinion the only "science" that matters on this subject are the opinions of those whom have lived it and recovered. Go survey the opiate addicts that didn't end up dead and find out what worked for them.

There is a problem of silent evidence and survivor bias here. What is important is not what they did that led to their recovery, but what they did differently (or, more generally, what was different in their circumstances) from those that tried to recover, but didn't.

So, IMHO, what is needed is not _just_ the opinions of those that recovered, but a longitudinal study to identify which, out the many factors that were involved in the recovery process, have been the most instrumental.

Not only what they did differently. It might be something they didn't do as well. Since data is laking any personal effort might be completely irrelevant and only the environment might make the difference. I presume there is a large personal effort involved but we don't know.

On survivorship bias: the B 17:s in 2nd world war that generally are used as the practical example of this principle had bullet holes exactly in those parts of the plane that were fine. The parts that had not taken a beating in the survived planes were the ones that needed more armourplating.

So, where are the psychological bullet holes in those who've not beaten addiction?

> There is a problem of silent evidence and survivor bias here. What is important is not what they did that led to their recovery, but what they did differently (or, more generally, what was different in their circumstances) from those that tried to recover, but didn't.

That's assuming they did anything different at all. It could just be that there is not a one size fits all treatment for this problem, and part of the solution is to match the right treatment for each particular addict.

While I agree with your points about collecting empirical and unbiased data, I want to point out that when it comes to opioids, "Science" is moving the goal posts. They are measuring social acceptability of a subject while under the influence of doctor-prescribed dope, while ignoring the numerous addicts who maintain similar levels of social acceptability while using Street dope, then declaring their method a "success".

Yes, fair point. This is a common problem for social studies. One must keep in mind and be explicit about the population the study sample is drawn from; and very cautious about extrapolating the findings to other populations.

I have a couple of friends on methadone, they are cordial, relatively together and in a totally safer place than prior. I would rather that than the other so it's legitimate approach in my eyes, they have the rest of their lives to figure out when they can stop.

"Detoxifications and drug free modalities, although appealing to an understandable desire for recovery without medications, produces only 5-10% success rate. Methadone maintenance is associated with success rates ranging from 60 - 90%. The longer the people are in this modality the greater their chances are of achieving stable long-term abstinence."

http://www.csam-asam.org/methadone-treatment-issues

> they have the rest of their lives to figure out when they can stop.

The answer is: never.

Only if they get into a program that guarantees they will be detoxified in 6 months(or so). This is rare unfortunately because it needs the addict's consent, which is rarely given. They usually choose the "open-ended" program because it's easier.

They only use methadone because it's a legal(but controlled) drug. It's not that much better than heroin.

never and alive is just fine, methadone satiates the addiction though does not really deliver a 'high' anymore so these friends can fill their lives with more interesting things, at some point methadone might get de-prioritised, in the meantime, I support them with love and encouragement, they recognised they were in a situation and took intelligent pro-active steps to move their lives forward, I'm not them, I'm not inside their mind, I don't know how hard it is for them, I'm not here to judge.

No one is judging no one. And you should keep supporting them any way you can.

But I am just stating facts.

> at some point methadone might get de-prioritised

But that is wishful thinking, not reality. Open-ended programs do not work. Period.

By far most people in such programs relapse multiple times. You can't expect from the addict to kick the drug off out of sheer will and good intentions.

> took intelligent pro-active steps to move their lives forward

You don't understand addiction and how it works. It has nothing to with intelligence or logic. When someone chooses an open-ended program is because the people around them force them to take some action and they choose the easiest one.

Again, no one is judging and no one said those people do not need love, quite the opposite. But open-ended programs destroy their lives.

You're talking in absolutes, with no references, do you have any supporting evidence, did you read the linked article, I seem to some good science on my side.

"For opioid addiction itself, however, the best treatment is indefinite, possibly lifelong maintenance with either methadone or buprenorphine (Suboxone). That is the conclusion of every expert panel and systematic review that has considered the question — including the World Health Organization, the Institute of Medicine, the National Institute on Drug Abuse and the Office of National Drug Control Policy."

https://fivethirtyeight.com/features/what-science-says-to-do...

I'm talking with more than 20 years of experience being close to people who follow these treatments.

One has to wonder why would we not choose a treatment(3-12 months, depending on the person/situation) since it can demonstrably help people recover completely from opioids and instead choose life-long dependence on particular drugs.

Are these the same scientists that think prescribing Vicodin, as if it's aspirin, is a good thing?

> One has to wonder why would we not choose a treatment(3-12 months, depending on the person/situation) since it can demonstrably help people recover completely from opioids and instead choose life-long dependence on particular drugs.

Who cares? Nobody talks this way about a person who has to take heart medicine every day to survive, and not that many talk this way about me when I take Lexapro every day to not get depressed. What makes methadone so different?

> What makes methadone so different?

You can survive without it for starters. Not the case with heart medicine I guess?

If you saw people, with the same condition as yours, having a good quality of life without medicine wouldn't you not wonder if that could apply to you too?

In the case of drug addiction, I've seen many people successfully kicking off the habit in months and living a perfectly healthy life, as if almost nothing happened.

Life-long methadone users? Not so much. I can tell that people really think it's different from heroin but it's not really. It's just regulated. Think about it ;)

> I'm talking with more than 20 years of experience

Experience is valuable but for driving systematic changes, unreliable. Its too easy to color personal experience with bias of many kinds. That's the entire point of science, to eliminate those biases and document the underlying evidence to support a claim like: "Methadone does not work."

> That's the entire point of science

Challenge accepted :D

Scientific fact 1: methadone doesn't alleviate the addiction. It actually feeds it to the point that it increases the patient's tolerance at which point you have to increase the dosage.

Scientific fact 2: methadone doesn't provide the "high". Totally true. That's why the vast majority of patients seek it elsewhere(alcohol, cannabis, etc).

Scientific fact 3: Life-long methadone users have relapses more than once. Most clinics/doctors supporting methadone brush it off as "it's quite normal and logical".

Scientific fact 4: innumerable people have been able to kick off opioid addiction by following long-term(but not life-long) therapies.

General fact: You'd be hard pressed to find a drug, other than methadone, that has been so controversial in its usage.

More facts: these panels of "experts" don't provide evidence that long-term recovery doesn't work, but they opine that "hey, methadone is the best, true story.". Show me data, show me science ;)

Isn't it way too convenient for the drug industry? Has it ever happened before, I wonder?

Isn't it weird that heroin addiction in US has increased because of the gratuitous opioid prescriptions?

https://www.theguardian.com/society/2017/mar/29/us-heroin-us...

We now have a methadone clinic in our local shopping center, right next to a large childcare facility. Since then, crime has gone way up. The grocery store now has armed guards.

This is not what a solution should look like.

>This is not what a solution should look like.

I'm not necessarily a supporter of suboxone / methadone / whatever , but this NIMBY rhetoric isn't helpful, either.

It's rare for the down-turn of an area to have one extraordinary cause.

I guess that the suggestion is that methadone clinics create crime where there otherwise wasn't -- but I don't see it that way in my community.

What I see these clinics provide is a centralization of potentially bad actors for authorities to keep tabs on while they seek guidance or pay court-ordered time to the system otherwise.

What's the alternative here? Cease these communal style clinics? If one believes in these treatment options whatsoever then it must be realized that cessation of these clinics would take that care option away from many people who may find legitimate use.

I don't have alternatives to the clinics , but I do have insight into what one should pay attention to when an area begins to struggle:

Income, education, and general upward mobility within society.

> It's rare for the down-turn of an area to have one extraordinary cause.

no it's not. he's talking about a single store. in my town it's the homeless shelter and halfway house that causes a 5 block radius around it to be a terrible place to live.

we're not talking about building more housing, or zoning for high density commercial/residential mixes, or building public transit, or eliminating cars from downtown cores, or building more bus routes, or bikeshares, or uber, or any number of things that people actually want. we're talking about methadone clinics and halfway houses next to where affluent people live.

if you pretend like it's hard to understand why people don't want those things in their residential/shopping neighborhoods, you're just going to alienate everyone you communicate with. you can't just invoke the magic 'nimby' and get people to change their minds. __they don't want these things next to where they live__.

> __they don't want these things next to where they live__.

Which is the precise definition of Not In My Back Yard...

yeah, and good luck convincing anyone, anywhere that building a methadone clinic in their back yard is a good idea.

here's another turn of phrase you might find handy: choose your battles.

I know some people complaining about the noise from child care in their neighborhood.

why should it be a problem? in the UK, methadone is normally dispensed from a regular pharmacy, just like any other prescription you might get from your doctor. I wonder if what you are seeing is that the clinic has been placed in a neighbourhood that already had high crime/homelessness/etc. since that is where the addicts who need its services are? it just seems odd that a clinic would be placed in an affluent area, where property costs are probably high, and the service users have to travel to get there, but maybe it's an american thing?

the methadone clinic near(ish) my house is a well known place to score dope.

the junkers have basically turned the nearest subway into hamsterdam.

McNulty: If Snot Boogie always stole the money, why'd you let him play?

Man On Stoop: Got to. This America, man

> I have a couple of friends on methadone, they are cordial, relatively together and in a totally safer place than prior.

From my work with injecting drug users about a decade ago: None prefers methadone, they only take it because, when in a treatment program, they get it for free and unadulterated. When it comes to actually ceasing consumption, at least on the mindvox drug users list, the consensus seemed to be, that is is easier when first switching back to heroin.

Ask your friends whether it is the methadone as a substance that helped them or the decriminalization and steady supply they don't have to worry about. From experience, I bet on the latter.

My read is that the science was principally this 'graph:

For opioid addiction itself, however, the best treatment is indefinite, possibly lifelong maintenance with either methadone or buprenorphine (Suboxone). That is the conclusion of every expert panel and systematic review that has considered the question — including the World Health Organization, the Institute of Medicine, the National Institute on Drug Abuse and the Office of National Drug Control Policy.

With four links in that last sentence.

Alcohol != opioid.

As I said in another comment, alcohol is an odd drug. It's mechanisms work very differently from opioids and needs very different behaviors and strategies to combat.

In my opinion you can't simply discard the debate as comparing apples to oranges... There are many similarities. It's a drug addiction at the end of the day.

So, we should give alcoholics naloxone?

Okay, so now we've established that alcohol and opiates do different things in the brain.

So, at this point, I'm going to ask you: "Why should you assume similarity rather than assuming difference?"

Just because viruses and bacteria are both harmful does not mean we should use antibiotics for both.

> Just because viruses and bacteria are both harmful does not mean we should use antibiotics for both

But getting rest and good nutrition will help the body fight both. So they work differently but some treatment is the same. Not unlike what gp was pointing out.

One of the most successful treatments for alcohol addiction is the Sinclair method which uses naltrexone and opioid blocker.

Going cold turkey from heroin is unpleasant.

Going cold turkey from alcohol can be fatal.

The issue with some of these therapies is more or less that they are defaults, not that the therapy itself is bad in itself.

12 Step programs for instance... well, they really don't have a great success rate. It seems like the success rate is around 5 to 10 percent for AA. (http://www.npr.org/2014/03/23/291405829/with-sobering-scienc...).

But for me, I think that the issue is less the program than it is the default option, often ordered by the courts. 12 step therapy probably does work with certain personalities. For others, it will do nothing, or maybe even make things worse.

This is probably the same for "tough love" type rehab programs. Some people would be okay with this. Others would react better with other options (your CBTs, BCTs, etc.)

I will say this from a "non-expert" perspective: suboxone honestly is what you want to do from a chemical perspective for opioids. Suboxone is a combination of a mild opiate (buprenorphine) and naloxone, a μ-opioid antagonist that's there mainly to prevent abuse.

For an addiction, chemically, moving to something milder seems like a great intermediate step, akin to some methods of getting off of nicotine (eg, slowly decreasing mg of patches etc). The nicotine patches don't work too well -- it seems like the effectiveness rate is only about 17% (http://www.mdedge.com/jfponline/article/60156/addiction-medi...). But this is a significant increase from placebo (another study -- https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0010505/ -- says 50-70% more likely).

Agree that there is no silver bullet; probably the best route out is a combination of something to handle the chemical side with some form of therapy to handle the other end. The type of therapy would probably have to heavily depend on the person, given that the therapy must be something the person is willing to commit to in order to work.