Evidence Based Treatment
Why Should You Care?
Kim Comstock MEd, LPC
Evidence-based treatment is the practice of chemical dependency treatment methods that have been scientifically proven effective. The US Department of Health and Human Services defines EBT as specific clinical guidelines that help bridge the gap between what researchers find to be effective treatment and what is implemented at the practice level. The problem is that the gap remains a wide chasm in many areas of treatment, especially with opioid dependence.
According to the National Institute of Drug Abuse, (NIDA), heroin use has remained stable across the country but opioid prescription abuse was up over 100% in some areas. (NIDA infofacts: Nationwide Trends). Opioid Treatment using methadone or buprenorphine (a new medication recently approved to treat opioid dependency) can be found in Opioid Treatment Programs, OTPs, and Office Based Opioid Treatment or OBOT. Both offer outpatient treatment for opioid dependency, addressing the problems associated with heroin and/or narcotic prescription pain medication within a multi-modality approach. Both treatment approaches are referred to as MAT, or Medication Assisted Treatment, defined by CSAT as: the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders. Research shows that when treating substance-use disorders, a combination of medication and behavioral therapies is most successful. Medication assisted treatment (MAT) is clinically driven with a focus on individualized patient care.
Methadone maintenance treatment (MMT) exemplifies MAT and evidence-based treatment. Because MMT has been researched for over 40 years it is the most widely studied chemical dependency treatment available today. These studies have consistently demonstrated that MMT is from 60%-90% effective in reducing or eliminating opioid use and its associated behaviors. The Veterans Administration states that methadone is the Gold Standard treatment for opioid addiction. Given the dire consequences to the addict and the cost to society of a return to injecting heroin (e.g., increased criminality, HIV infection rates, and mortality), indefinite maintenance in [methadone/buprenorphine treatment] is the only satisfactory treatment alternative for opiate dependence. A study in the March 8, 2000 edition of JAMA shows that traditional methadone treatment therapy is superior to both short-term and long-term detox treatment as a method to treat heroin dependence. In fact, all major US government agencies associated with chemical dependency including SAMHSA, CSAT, NIDA, and DEA; agree that MAT is the gold standard treatment for opioid addiction.
Discontinuation of MAT can be deadly. This is a finding in a review of scientific literature published in the Mount Sinai Journal of medicine 2001 by Magura and Rosenbloom which compared the effectiveness of various treatment approaches. Leaving Methadone Treatment: Lessons Learned, Lessons forgotten, Lessons Ignored found that almost all detoxified addicts rapidly relapse to heroin/opiate abuse, that death rates are greatly increased following discharge from MMT, and that treatment providers should be very cautious about imposing barriers to long-term opiate replacement therapy.
As the research states, the conflict between the evidence-based school of thought and that of abstinence-only treatment not only hurts clients -- it sometimes kills them. Following are three real-life examples that demonstrate the effects of the gap between research and practice.
One patient was informed by a government employee assistance program case-manager that he would have to be off of methadone before he could receive more services from the organization. He tapered his dose, against medical advice, left treatment, and overdosed within 6 months. He left behind his 10-year-old daughter of whom he was the sole caregiver.
Another patient was admitted to an in-patient psychiatric hospital for depression where they immediately, and rapidly, detoxed him from methadone, against his wishes. He overdosed within 3 months of being released. He also left behind school-age children.
And another patient was admitted to an in-patient drug treatment program for a secondary drug-abuse problem (other than opioid dependency). This program also saw fit to detox him from methadone. Within days of his release he also died from an overdose of heroin.
Had these patients been maintained on methadone it is very likely they would not have died from an overdose of opioids. In all of these examples opioid dependency was NOT the presenting problem. The patients came requesting help for one problem, and yet they left with a problem that was previously under control; opioid addiction. Death is what is risked by imposing an abstinence-only bias on opioid dependent individuals.
Methadone, as a treatment, has a three-fold effect on the patient. One, it works to eliminate withdrawal symptoms. Two, it reduces or eliminates cravings for opioids. Three, it actually serves as a protective barrier against the effects of opioids introduced to the system. In other words, an adequate dose of methadone will prevent or significantly reduce the effects of other opioids such as heroin because it blocks the targeted receptor sites. Buprenorphine has a similar effect. Not only does the individual not feel the effects of the opioid, they are also protected from the dangers of overdose. The receptors are already occupied by the methadone so other opioids cannot bind, thus have little, or no effect.
Secondary drug abuse is on the rise. Today, approximately two-thirds of heroin and Opioid prescription drug abusers entering substance abuse treatment reported at least one secondary substance of abuse AT Forum 2008. Thus, inpatient treatment settings will be confronted more than ever with the need for MAT within their programs, while they address secondary presenting issues. It is shameful that in this country a MAT pt is not allowed the same rights to adequate care for addiction and mental health issues as non-opioid dependent people, simply because they ARE MAT patients. Others with chronic relapsing diseases are not required to forgo their life-saving medications just in order to receive care for other presenting disorders. MAT patients are confronted with this stigma even in 12-step groups. The Narcotics Anonymous bulletin statement # 29 states that MAT patients can participate only by listening!
Evidence-based treatment incorporates the best of all modalities, including abstinence-only when clinically appropriate. Of course complete abstinence is the most desirable goal, but the science shows that goal often unrealistic. The Australian government dedicated 7 million dollars towards studying the efficacy of various detox treatment for opioid dependency. The National Evaluation for Pharmacotherapies for Opioid Dependency reported the following opioid abstinence rates at 7 days post-detox for 1,425 participants:
- Rapid detoxification under sedation - 60%
- Rapid detoxification under anesthesia - 58%
- Conventional in-patient detoxification - 24%
- Buprenorphine out-patient detoxification - 12%
- Conventional out-patient detoxification - 4%
Keep in mind these numbers reflect 7 days only, post-discharge. Decades of studies have shown that the number of post-detox patients who remain free of opioid use for a year average from 10% - 20%. MMT success rates have been consistently proven to average around 80%. Evidenced based treatment principles state that the best treatment is the treatment that works.
The State of Texas supports and requires evidenced-based principles and practices in all their programs. Texas stipulates that all programs publicly funded must offer methadone/buprenorphine maintenance treatment or risk losing their funding. The Texas State Department of Health Services states in its substance abuse rules and regulations 447.303(a)(4) Programs must ensure that methadone/[buprenorphine] clients have access to inpatient, residential, or outpatient treatment for medical, surgical, psychiatric and non-opiate chemical dependency conditions without interruption of pharmacotherapy services. Texas is not the only state incorporating such rules as the trend continues toward universal acceptance of evidenced based principles.
The number of MAT patients in the US has almost tripled in eight years from 160,000 in 1999 to 565,000 in 2007 (DEA). The patient deaths noted above are but a fraction of the number of individuals affected by the abstinence-only bias in our country. This translates into possibly thousands of deaths. A large part of the problem is what is referred to as the use of treatments out of tradition and habit, not because of evidence of their effectiveness. McNeese and DiNitto Chemical Dependency A Systems Approach (2005)
As addiction professionals we are ethically obligated per our licensure to ensure that every client is aware of all treatment modalities available to them. The client should understand the inherent risks, benefits and success rates associated with each and every treatment approach available. These include evidence-based AND abstinence-only modalities. Whether you are a professional practitioner in the field or someone who has been touched by addiction in some form or another, keep in mind everything you’ve just learned. Know that your words can do irreparable damage, or they can save a life.