Take Home Messages for Patients
- Opioid Use Disorder Can Last for Decades
- Recovery is not a Cure
- Return to use carries a Risk of Death.
- Stopping Suboxone after Brief Treatment carries a risk of using again.
- Some persons maintain long-term recovery without buprenorphine
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 miserable corner!
“ I am sick”
We both know that the person has lost control: spent too much; feels bad- the pain and distress shout. The fear is:
“ 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. In contrast, I think:
“ Feeling normal tells me Suboxone is working- not that the disease has been 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; NPI:1306899943
Maintenance of Certification in Addiction Medicine, American Board of Preventive Medicine
A Complicated Read: A Deep Dive into What Medical Literature Tells Us.
Your Life!
Your Choice!
How will you use the literature of medicine for guidance?
Your Passage into Your Unknown Future
The Language of medicine is a language of restraint. I will present you with complicated, difficult “reads” that reveal what the studies show.
Sorry about this. I think in complexity. I live in complexity. Complexity is my life, as I began as a philosophy and religion major in college. I love the complexity of medicine. My life is now lived in scientific, philosophical, and literary complexity. I study medical literature for fun.
Returning to Planet Earth requires me to speak in a translated English-understandable, but fundamentally valid, precisely articulated.
Your decisions about how you use medical literature for your guidance is your choice. I present you with “my take”, with the reference for your detailed review.
The Disease of Opioid Use Disorder Unfolds Over Years, Not Months
Price, Risk, and Spitznagel (2001) conducted a landmark 25-year retrospective cohort study.[i] The authors examined the full trajectory of opioid use disorder 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 remission. In this study, fewer than 9% of the active users were engaged in treatment at any single time. The same study also showed that many people entered remission, often without being in formal treatment at the time. Remission without treatment is possible, but the course is normally prolonged.
Hser and colleagues provided a comprehensive review, published in Harvard Review of Psychiatry in 2015, which synthesized 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.
Abstinence tells us whether opioids are being used. Remission tells us whether the syndrome of opioid use disorder is currently active. Neither abstinence nor remission is, by itself, a cure
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 in 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 disorder, 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 were often recurrent, and many were temporary rather than permanent. ”
Nosyk ,et al had their study 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 participants 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.
The Disease of Opioid Use Disorder
To understand the disease of opioid use disorder, the following characterizations of pathology 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 suppressed, not resolved
The evidence is clear: Periods of abstinence alternating with periods of use are the natural course of Opioid Use Disorder
Short-Term Buprenorphine Treatment is Rarely Effective.
In my small practice in Nashville, some patients remain on suboxone for multiple years – leading their full rich lives. This is called remission,
In contrast, many patients stay for less than a month or less than a year. They rarely tell me that they are leaving. I simply never see them again. Some see another physician. Most appear to simply stop.
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] and 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.
In summary, short-term detoxification in treatment of opioid use disorder has a very low probability of success.
Present and Future Paths with Suboxone
There are four crossings with buprenorphine.
- A brief crossing: You choose to use Suboxone briefly.
- A longer crossing: You choose to use Suboxone for a few years.
- Crossing back and forth: Your choice is to stop and return. You may repeat this choice several times in a lifetime
- A Lasting crossing: You choose to continue Suboxone for many years, sometimes for life.
How Patients with Type One Diabetes Think
Let’s compare your disease to Type 1 Diabetes. Type 1 diabetes was uniformly fatal before Banting and Best discovered insulin as the treatment. Banting and Best changed Type 1 diabetes from a rapidly progressive fatal disease into a chronic illness with both new complications and a much longer life. 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.”
My life as a diabetes doctor is different from my life as a Suboxone doctor.
Conclusion: Returning to Corner of Fear and Hope
Your Life! Your Choice! Your decision about guidance from medicine!
The corner of Hope and Fear is challenging. The first dose of suboxone will provide you some relief from suffering. Continuing doses of suboxone reduce your suffering. Withdrawal finally becomes part of your immediate past.
After your immediate suffering has disappeared, you are left to think
“ Why am I on Suboxone?”
“ How long will I stay on Suboxone? “
“How do I maintain my recovery in my future?”
‘ How will I understand the lessons taught in medical literature ”
Your future is unknown. Your decision about Suboxone is a major life-altering decision. The rightness of your choice about the length of your suboxone treatment will be revealed to you in your future.
This series of blogs aims to help you better understand the complexity of your decision about the duration of treatment. It is your choice to think deeply, or not think at all, about the duration of treatment
[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
