Striking a nerve with Methadone revisited

I received several replies from methadone advocates; I am going to highlight portions of their comments and respond to them. But first I would like to make a personal comment to the writer who spoke of her pain treatment with methadone–  and I would like to thank her for her heart-felt letter, and say that I agree that opiates must be available for adequate analgesia in the case of cancer and other serious illnesses. 

I think that the over-use of opiates for chronic back pain and other inappropriate uses are part of the reason why opiate use is ultimately limited in legitimate indications. And that is a shame for everyone– for the cancer patient with pain, for the doc who is investigated for prescribing appropriately, and also for the patient with low back pain who is destroyed by narcotics, all the while thinking they are necessary and helpful.

But in this case I am referring to methadone for addiction ‘maintenance therapy’, and the ‘methadone advocates’ that wrote to complain that I had ‘dissed’ methadone.  In an earlier post I noted the mention of ‘countless experts’ who supported methadone use, and I asked, which experts?

Their replies contained references that I will eventually list in case anyone wants to look them up and read them in their entirety—as I did. I have the benefit of access to the online library and search functions of a major medical school—every time I use it I think about working on my thesis in 1986, reading science citation index each morning, writing down references, and then going up and down the back stairs in the ‘stacks’ of the medical library as I searched for the articles, sometimes needing to dig through bins of unshelved books and journals to find the right one…

I can now do something at home in 30 minutes that used to take 4 hours at the med center. These efficiencies from the internet hopefully partially make up for the hours wasted on the internet by society… leaving me with some hope for the future of the human race. But I digress…

It is important to look up entire articles and read them from beginning to end; many times a sentence will be quoted by someone to make a point, but taken out of context in a way that completely changes the meaning of the sentence. Sometimes comments will get handed down from article to article like that old ‘telephone operator’ game, where a comment is passed from person to person around a large circle. Again, comments are changed a bit in each ‘generation’ of article until a whole new comment is generated. I would encourage ‘Arm-me’ to do this exercise with the comments that he/she provided; or just read on… I will get to the articles after responding to the more personal comments.

There was an accusation of a ‘financial motive to prescribe bupe’— I have been at the 100-patient max and closed to new patients for months; I recently re-opened for a few more but unfortunately there is no shortage of supply of addicts in my part of the country (although apparently not enough addicts to keep the methadone clinics open, as several have closed). As for ‘researching methadone for the benefit of my patients’, I explained in ridiculous detail in a prior post how my life has ended up devoted to opiate addiction— as both an addict and as a doc treating addicts—and I know methadone pretty well.

As for the scientific articles, here is a portion of one comment, out of several comments made by the methadone advocates: Here is one of the more extensive reviews of 24 clinical studies re: methadone vs. buprenorphine. In fact when they first started prescribing suboxone they told patients on methadone if they didn’t do well on 60-80mg of methadone they “most likely” weren’t going to do well on Suboxone.

I don’t know who Arm-me is referring to by ‘they’. He provided this reference: Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. – Mattick RP – Cochrane Database Syst Rev – 01-JAN-2008(2): CD002207. This references a ‘meta-analysis’; a meta-analysis is done by taking a number of separate studies which often have no significant findings, and adding them all together in order to create something statistically ‘significant’.

This type of study is sometimes useful to summarize the findings of other studies, but one has to look at the nature of the collected studies—24 in this case—before drawing conclusions. This meta-analysis, for example, includes studies that predate DATA 2000 (the Act of Congress that legalized the Suboxone program), before which bupe was available only as a chemical dissolved in a liquid— and the use of the drug was very dissimilar to modern use of Suboxone.

In the meta-analysis the author referred to ‘low, moderate, and high-dose’ buprenorphine; the ‘low-dose’ studies are irrelevant to current practice, as we now know that it takes 8-16 mg of bupe to suppress cravings. I know I am starting to bore all of you…

The other reference was: Am Fam Physician 2006;73:1573–8, 1580: Managing Opioid Addiction with Buprenorphine—it was not a study at all, but rather a review article that is filled with the ‘telephone operator game’ quotes I mentioned earlier.

Arm-me listed quotes from this review article, which the review article itself copied from other articles, which had also copied them… I tracked them back and found that they originated from two articles: one in 1997 (before Suboxone was patented) and the other in 2001—which was another garbage meta-analysis.

Bottom line—there is nothing in those references that shows that methadone is preferential to bupe in any circumstance—UNLESS you compare methadone to a subclinical dose of bupe, which is where the quotes came from. Yes, it is true that in 1997, methadone in high doses was better than 2 mg of bupe. But no kidding—that is why nobody who knows what they are doing limits bupe to 2 mg. Another of the quotes referred to a study that measured ‘success’ as staying in the study—at a time when Subox was not available and the dosing had to be done at the study center using a liquid form of buprenorphine. Talk about apples and oranges… there is a big difference between going to a med center and waiting to have bupe squirted in your mouth vs dosing with Suboxone at home.

There are some other things about the latter reference supplied by Arm-me-the-methadone-guy that make me wonder about the bias of the article.  The article has a table with a cost-comparison of methadone vs Suboxone; in the comparison the author lists the price of Suboxone as ‘$100 for a 15-day supply of 2 mg’, and methadone as ‘$30 for a 30 day supply not including counseling’. 

Suboxone is sold by Wal-Mart for a little over $5 for 8 mg; at the full daily dosage of 16 mg the cost is $300/month.  Why does the author use a 2 mg dose (that nobody uses for maintenance), which implies a much higher cost per mg?  And then the methadone price of $30 for 30 days– how many people out there have a clinic that charges one dollar per day?  In Wisconsin the charge ranges from $10- $15/day!  Either the author is being deceptive, or he doesn’t understand how things are– either case making his opinion a bit suspect a best.

(addendum: buprenorphine 8 mg #60 now costs $20 at Walgreens with GoodRx coupon, in 2023)

I have to wrap this up… but there were a couple more things written that worked me up a bit.  Arm-me took issue with my comments about AA and NA, suggesting that there is not data to support the efficacy of that approach— but there are plenty of studies supporting the 12-step approach and so I am not sure where such an impression came from. I’ll provide one of the most recent ones and he can use the references in it to track back to others: Witbrodt J. Bond J. Kaskutas LA. Weisner C. Jaeger G. Pating D. Moore C. Day hospital and residential addiction treatment: randomized and nonrandomized managed care clients. Journal of Consulting & Clinical Psychology. 75(6):947-59, 2007.

Ironically my exchange with Arm-me only reinforced my opinion of methadone programs. He ended his message with this bizarre comment in reference to AA and NA: ‘if you can show me studies that prove that utilizing these support groups make your chances of sobriety better than hoping for a spontaneous remission, than I will gladly add the research to my “bookmarks” on mdconsult’. This a comment from a person who presents himself as knowledgeable about addiction—and as a ‘methadone advocate’. In contrast, the training for docs who want to prescribe Suboxone recognizes, teaches, and requires an understanding that medication is only a small part of recovery.

I have seen so many miracles in those who ‘get it’— those who ‘cling to AA as a drowning man seizes a life preserver’ (or something like that—taken from an AA reading)— as have other fortunate people who have been forced to make the tough changes that AA and NA require. That Arm-me would call them ‘support groups’, and then compare their value to ‘hoping for spontaneous remission’, tells me that he knows nothing of ‘recovery’ at all. And now I understand the whole problem here—the source of the tension. In talking to a person on methadone, I am talking to an active, using addict. Maybe the need for dope is temporarily filled—maybe he has even learned to repress the cravings into the unconscious. But the addict BS and loss of insight is still there. But of course, why wouldn’t it still be there?

After all, methadone is just another opiate agonist.