Executive Summary
- Opioid Use is a Disease that Lasts for Years to Decades
- Abstinence is not a Cure
- Opioid Use is a Serious, Long-Lasting Disease
- The Disease has a Significant Risk of early- premature- death
- Short-Term Suboxone Treatment has a low Chance of Long-Term Success
The Parable of Living on The Corner of Fear and Hope
On his first visit to my Nashville office, the patient sits on the corner of Fear and Hope. A truly miserable corner!
“ I am sick”
We both know that the person has lost control: spent too much; feels bad. The Pain shouts. The fear is that treatment will not work- not work well enough- not work fast enough.
The Hope is “This is the worst flu I have ever had. Flu passes: one week; one month; no more than six months. I will be cured. A shot of penicillin when I was a kid did the trick”
On the second visit, if there is a second visit, I am delighted. If the person shows up a little longer-perhaps even a few months- I am overjoyed. If the person quits, I am not surprised.
The person believes he is cured.
Introduction of Author
William Conway, MD, FACP, FASAM
Independent Physician: General Internal Medicine and Addiction Medicine
Writer Exploring Life’s Lessons from Autobiographies of Persons with Addictions
Fellow, American College of Physicians (Internal Medicine)
Fellow, American Society of Addiction Medicine
Member, American Academy of Addiction Psychiatry
Current Areas of Interest
- Diabetes
- Women’s Health
- Aging and Longevity
Tennessee License: MD35708
Maintenance of Certification in Addiction Medicine, American Board of Preventive Medicine
The Disease of Opioid Use Unfolds Over Years, Not Months
The natural history of opioid disorder is measured in years to decades. Opioid Use Disorder does not just go away.
Price, Risk, and Spitznagel(2001) had a landmark 25-year retrospective cohort study.[i] The authors examined the full trajectory of opioid use disorders in the context of substance use disorders
Across the drugs studied, the mean time from initiation to last remission ranged from approximately 9 years to 14 years. These findings illustrate how substance use disorders can persist for many years before lasting remission. In this study, fewer than 9% of the active users were engaged in treatment at any single time.
Hser and colleagues provided a comprehensive review, published in the Harvard Review of Psychiatry in 2015, synthesizing multiple long-term cohort studies.[ii] Hser confirmed the findings of Price et al. Stable abstinence was defined as at least four months of continuous opioid free use.
Across multiple long-term cohort studies:
- Less than 30% achieved 4 continuous opioid free months, even after 10 to 30 years.
- The majority never achieved sustained remission at any point examined,
- Death, or mortality, was 6 to 20 times that of the general population.
Opioid Use Disorder is a serious, long-lasting illness.
Abstinence Without Suboxone is not a Cure
Nos and colleagues(2013) provided evidence. In a published 33-year observational cohort study of 471 men enrolled I the California Civil Addict Program. 932 distinct episodes of abstinence were recorded for these 471 men observed for over three decades. This averaged two episodes of abstinence for each person. More than 60% of the episodes lasted over one year. Many patients subsequently returned to opioid use, although some abstinence episodes continued through the end of follow-up. Abstinence was often recurring, but not necessarily final. The study’s conclusion:
“Abstinence episodes often recurred, and many were temporary rather than permanent. ”
Nosyk et al. had their findings confirmed by the Termorshuizen et al. (2005) Amsterdam Cohort Study of Long-Term Drug Users over 20 years.[iii] Among those persons who survived the 20 years, only 27% had achieved stable abstinence. The fact that many of the persons were using opioids is overshadowed by the observation that the disease had killed a substantial portion of the study population before they could reach the 20-year mark. Hence, this 27% survival-conditioned abstinence rate is an optimistic estimate of the actual population-level outcome.
To understand the disease of opioid use disorder, the following characterizations apply
- Abstinence is a biomarker of status, not cure
- Abstinence is not a surrogate for disease resolution
- The neurobiological substrate for the disease remains
- When suppression of the disease occurs with buprenorphine, the disease is treated or suppressed, not resolved
The evidence is clear: Periods of abstinence are a recurring phase of the natural course of Opioid Use Disorder, not evidence that the condition has resolved
Short Term Buprenorphine Treatment is Rarely Effective.
In my small practice in Nashville, some patients remain on suboxone for multiple years- in remission, leading their full, rich lives. Many patients are present for less than a month- or less than a year. Rarely do they discuss this with me, why they leave. I simply never see them again. From notifications sent to me from Controlled Substance Monitoring Data, very few who leave continue treatment with another physician.
The data from Price, Nosyk, and Termorhuizen establish the long view of decades of substance use disorders in a 25-year follow-up study. However, what happens in much shorter time frames commonly employed by my patients and certainly employed by the payers, has not been explicitly defined by professional literature.
To answer the question of the effectiveness of short-course outpatient buprenorphine treatment followed by discontinuation, detoxification studies offer useful- although indirect- evidence.
In an inpatient detoxification cohort receiving one week of detoxification, Morgan and colleagues(2020) found that 65% of their patients were using heroin at three months,[iv]. At nine months, 72.4% used heroin. Morgan notes that it was a common pattern for his patients to turn to alcohol heavily while returning to heroin. The active neurobiological drivers of compulsive use remained intact when the patient walked out of the detox unit. The rapid onset of heroin use is the predictable biological reassertion of an undertreated chronic illness
In summary, short-term detoxification in treatment of opioid use disorder has a very low probability of success.
Present and Future Paths with Buprenorphine
Let’s review again how persons relate to their opioid produced disease, and their common choices about treatment with suboxone.
There are four crossings with buprenorphine.
- A brief crossing: Buprenorphine is taken for a brief period and stopped.
- A longer crossing: Treatment continues for months to years before stopping.
- Crossing back and forth: Treatment begins, then stops, and later restarts, with the pattern repeated more than once.
- A Lasting crossing: Buprenorphine remains part of life for many years, sometimes for life.
In this blog, we are reviewing a brief crossing. At the end of the brief crossing, the person does not know his future. The future will unfold with life’s twists and turns.
Your Life! Your Choice!
What Natural History Means for Buprenorphine Treatment
Medical literature is not your prediction rule. Only God knows your future. I believe ignoring the lessons taught by carefully produced medical literature is as foolish as believing medical literature is Moses producing 10 commandments. In my view, this is a rational decision.
Medical Literature is summarized by:
- Opioid Use is a disease that lasts for Years to Decades
- Abstinence is not a Cure
- Opioid Use is a Serious Disease, Long-Lasting Disease
- The Disease has a significant, often early risk of death
- Short-term Suboxone Treatment has a low Chance of Long-Term Success
Let’s compare your disease to Type 1 Diabetes. Type 1 diabetes was uniformly fatal before Banting and Best discovered insulin as the treatment. Their discovery changed Type 1 diabetes from a rapidly progressive fatal disease into a chronic illness with both new complications and a much longer life. In other words, Type 1 diabetes became a serious chronic illness.
I have never had a mother of her type 1 child confidently declare to me:
“ My child is cured because yesterday’s blood sugars are relatively normal.”
While reasoning by analogy is considered a flaw in logic, in fact, this analogy does communicate a fundamental truth: You can stop treatment for a serious, predictably fatal illness: You can continue treatment for your serious illness, accepting the burdens of treatment.
Conclusion: Returning to Corner of Fear and Hope
Suboxone has not cured you. Suboxone provides proven benefit when taken. When Suboxone stops, your life and your risk are different.
Your Life! Your Choice!
[i] Price RK, Risk NK, Spitznagel EL. Remission from drug abuse over a 25-year period: patterns of remission and treatment use. Am J Public Health. 2001;91(7):1107–1113. doi:10.2105/AJPH.91.7.1107
[ii] Hser Y-I, Evans E, Grella CE, Ling W, Anglin DM. Long-term course of opioid addiction. Harv Rev Psychiatry. 2015;23(2):76–89. doi:10.1097/HRP.0000000000000052
[iii] Termorshuizen F, Krol A, Prins M, van Ameijden EJC. Long-term outcome of chronic drug use: the Amsterdam Cohort Study among drug users. Am J Epidemiol. 2005;161(3):271–279. doi:10.1093/aje/kwi035
[iv] Morgan N, Daniels WMU, Subramaney U. An inverse relationship between alcohol and heroin use in heroin users post detoxification. Subst Abuse Rehabil. 2020;11:1–8. doi:10.2147/SAR.S228224
