What works?

Nobody’s asked me.

Nobody’s asked any of the many competent addiction doctors practicing in Maine.

At least nobody with the power and money to take action based on facts.

What is the best thing to do for the thousands of young people in this state suffering from heroin addiction? How can we help them climb out of the abyss of obsession and compulsion and end the frenzied, relentless pursuit of opiates that consumes their days? How can we bring them back from the brink of overdose and death?

Well, doctors are always handing out unsolicited advice, telling people what they don’t want to hear, such as eat less, drink less, quit smoking.

So I’ll tell you.

Treatment is what works. Treatment with methadone or buprenorphine (aka suboxone).

Please understand, treatment is not replacing one opioid with another. It is not just giving the patient a legal opioid to take the place of an illegal one. Methadone or buprenorphine are both opioids, but used correctly patients do not get high on either drug. Methadone occupies about 30 percent of our opiate sites. Buprenorphine only partially activates these sites. Both are long acting, so patients do not experience the extremes of withdrawal and craving that are the essence of addiction and that drive them to keep using, despite the chaos, devastation and pain for their families they know their addiction is causing.

We have known for decades that 80 percent of patients do well in methadone maintenance programs. They get jobs, take care of their kids, stay out of jail. Their rates of infection with HIV and HCV, their rates of incarceration, overdose and death plummet.

We also know that when they are tapered off methadone 80 percent relapse within 12 months.

We have less years of data on patients treated with buprenorphine, but the results are the same. The great majority of patients succeed in putting their lives back together, work, reconnect with their families, raise their children, live normal purposeful lives. The success rate is up to 75 percent in some studies.

What happens when they come off? Ninety percent relapse within a year.

What about naltrexone?

Naltrexone is another medicine used for opioid addiction and can be taken as a pill or as injection. It works better in the long-acting shot form, but it’s very costly. It functions as an opiate blocker, so if a patient shoots heroin while they are taking naltrexone, they will be wasting their time and money. The heroin will have no effect. But naltrexone does not treat cravings for opiates and patients often drop out of treatment. It is still not clear how helpful it will be.

What else do we know about treatment?

Nothing is perfect.

Some patients will shoot or sell their buprenorphine. Some patients on methadone will continue to abuse other drugs. But the vast majority of patients in treatment turn their lives around.

What doesn’t work?

For patients who go to detox, spend 5-7 days, coming off drugs and getting some minimal exposure to AA and counseling, relapse rate is 95 percent. Detoxification is not treatment. It is only the first and necessary step to seeking treatment.

Intensive residential rehabs, many outlandishly expensive, often not covered by insurance, even those lasting many months, have little long-term success. Within two years of treatment relapse rates are about 80 percent.

What do these numbers tell us?

• That opiate addiction is a chronic relapsing disease.

• That it is treatable. In fact, we have very good treatment for it.

• That some patients — about 20 percent — can recover without methadone or buprenorphine.

• That counseling and group and rehab are important for learning new ways of coping with stress, loss, trauma, loneliness, anger. But alone, without methadone or buprenorphine, behavioral treatment has about a 20 percent success rate.

I currently have 55 patients on buprenorphine/naltrexone. Six of them are doing poorly, relapsing to alcohol or other drugs. One is relapsing to opiates. The other 89 percent are doing very well. I see an average of 15- 20 active heroin addicts in detox every week. All of them are chronically relapsing. I have seen most of them before and will see most of them again. Again and again and again. They have no insurance, no MaineCare. Detox is as far as they get. They return to the streets and use again.

For our 16 beds at Milestone we get more than 100 calls per week. Those are only the calls we can answer. Is Milestone the last detox in Maine? It seems like it. We are the only place that will admit opiate addicts, because insurance will no longer reimburse hospitals for opiate detox. We have only three beds for women. Are these three the only detox beds for women in the state of Maine? It seems like it. The patients call are desperate for help, and we have to turn most of them away.

Why am I telling you this?

Because each day I have to look another young man or woman in the eye and know there is no hope I can give them.

Mary Dowd, M.D. is a family practice physician who lives in Yarmouth.

Author’s note: The facts and data in this article were largely based on a research paper titled “Maintenance Medication for Opiate Addiction: The Foundation of Recovery,” Journal of Addictive Diseases, July 2012, available at www.ncbi.nlm.nih.gov/pubmed/22873183, and “ASAM National Practice Guidelines for the use of medications in the treatment of addiction involving opioid use,” June, 2015.

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