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I read this, as a recovering addict that went through my own hell mostly from alcoholism, and wondered where the "science" part was? For instance this sentence

I read this, as a recovering addict that went through my own hell mostly from alcoholism, and wondered where the "science" part was? For instance this sentence "More than 13 percent of its participants died after treatment,1 mainly of overdoses that could potentially have been prevented with evidence-based care." The argument is that they "could" have been prevented but how do they really know that? How many people in general die of an overdose after X number of stays in a rehab? Through my own experiences going to rehab, I have known of many people who die. The fact is you can't predict which people will "get" it any better than you can predict if it will rain next month. I also disagree with this notion that being on suboxone or methadone indefinitely is a legitimate solution. Like what? You're advocating to stay on a drug the rest of your life? That isn't recovery at all, it's a band-aid that will likely lead to relapse and promotes a perpetual notion of being sick. I also disagree that their supposed evidence that CRAFT gets twice as many people into rehab has much relevance. How many of those people relapsed? How many of the people that didn't go to rehab ended up overdosing OR recovering? We don't get the whole picture so the "evidence" is mute. They knock 12-step which is fine but it turns out that it works for millions of people. There is no silver bullet here. While I have mixed feeling about the "tough love" approach, I can tell you from personal experience that the only reason I'm not buried right now is because at a certain point the floor dropped out too low, my family and friends abandoned me, I lost everything for a moment, and the pain and horror reached a level that finally I had a change of psyche on my OWN and realized I wanted to get better. 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.

bsder 9y ago
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.
- taylorswift_ 9y ago
  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.
  - bsder 9y ago
    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.
    - rdtsc 9y ago
      > 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.
    - JamesBarney 9y ago
      One of the most successful treatments for alcohol addiction is the Sinclair method which uses naltrexone and opioid blocker.
  - DanBC 9y ago
    Going cold turkey from heroin is unpleasant. Going cold turkey from alcohol can be fatal.
rbobby 9y ago
> 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/ 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.
- taylorswift_ 9y ago
  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.
  - KGIII 9y ago
    It's not always about recovery, but harm reduction.
    - pnutjam 9y ago
      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.
tudorw 9y ago
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 http://www.csam-asam.org/methadone-treatment-issues
- rantanplan 9y ago
  > 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.
  - tudorw 9y ago
    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.
    - rantanplan 9y ago
      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.
setrofim_ 9y ago
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.
- fsloth 9y ago
  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?
- Ntrails 9y ago
  > 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.
- CodeWriter23 9y ago
  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".
dredmorbius 9y ago
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.
soundwave106 9y ago
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-science-doctor-debunks-12-step-recovery 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-medicine/what-most-effective-nicotine-replacement-therapy 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/ 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.

bsder 9y ago

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.

taylorswift_ 9y ago
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.
- bsder 9y ago
  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.
  - rdtsc 9y ago
    > 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.
  - JamesBarney 9y ago
    One of the most successful treatments for alcohol addiction is the Sinclair method which uses naltrexone and opioid blocker.
- DanBC 9y ago
  Going cold turkey from heroin is unpleasant. Going cold turkey from alcohol can be fatal.

rbobby 9y ago

> 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/ 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.

taylorswift_ 9y ago
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.
- KGIII 9y ago
  It's not always about recovery, but harm reduction.
  - pnutjam 9y ago
    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.

tudorw 9y ago

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

rantanplan 9y ago
> 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.
- tudorw 9y ago
  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.
  - rantanplan 9y ago
    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.

setrofim_ 9y ago

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.

fsloth 9y ago
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?
Ntrails 9y ago
> 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.
CodeWriter23 9y ago
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".

dredmorbius 9y ago

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.

soundwave106 9y ago

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-science-doctor-debunks-12-step-recovery 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-medicine/what-most-effective-nicotine-replacement-therapy 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/ 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.