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Foundations conference session exposes divisions on medication treatment

October 2, 2014
by Gary A. Enos, Editor
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A spirited breakout session on medication-assisted treatment for addictions at this week's Moments of Change conference in Palm Beach, Fla., illustrated the wide spectrum of views that persist on medication's place in the continuum of care.

The Sept. 29 session was led by Roland Reeves, MD, FACS, medical director of Destin Recovery Center in Florida's Panhandle, who has integrated medications such as buprenorphine and injectable naltrexone into clinical care at his treatment facility but who remains a staunch critic of what he sees as rampant irresponsible prescribing in the field.

“Maintenance medications don't fix anything,” said Reeves, who has posted blogs for Addiction Professional on physician issues in addiction treatment. He added, “Buprenorphine is greatly misused. Ninety-eight percent of doctors … use it as a pill mill.”

Reeves' strongest criticisms were leveled at methadone maintenance treatment, and this led to some of the more compelling questions from the breakout session's audience, mainly in the form of a strong rebuttal from an advocate of methadone as a life-saving treatment.

Reeves, who has a background in vascular surgery, acknowledged that the only job from which he was ever dismissed took place at a methadone clinic. “In my two years there, I never saw one patient wean off methadone,” he said.

His comments about methadone elicited a strong response from a conference attendee who emphasized methadone treatment's ability to keep an opioid-dependent person alive while an attempt is made to engage him/her in additional services. But Reeves expressed frustration over harm reduction strategies that become an end point, serving for some professionals as a tacit admission that because there are many treatment failures in addiction, a lifelong commitment to maintenance medication is the highest goal someone can reach.

“Are we public health ministers or advocates of individual wellness?” Reeves asked. “In my opinion, methadone will never advance more than being a public health service.”

Facts on buprenorphine

Reeves' presentation on the opening day of the Foundations Recovery Network-sponsored conference offered a mixed assessment of buprenorphine. He called the drug a highly effective pain medication and added that he has been able to see good results in his program for many opioid-dependent patients who use the drug for a few months (as long as they are held accountable for participating in a broad-based treatment program).

He added in reference to resistance to medication-assisted treatment in the 12-Step community, “I firmly believe that if Bill W. were alive today, Suboxone would be part of the [AA] program,” since the AA co-founder was treated with psychotropic medication himself.

Yet Reeves also said that the treatment field lacks protocols for post-detox use of buprenorphine, and says prescribing professionals were sold some untruths about the medication—he referred to a 2013 article stating that buprenorphine has become the most commonly misused opioid in Finland.

Reeves made it clear that he believes addiction treatment professionals must use all tools to combat what he considers the most powerful disease he has ever treated. One of his presentation slides read, “Recovery must include objective and real changes in the reward/learning/drive portion of our brain.”

He added, “I see more deaths here than I did in vascular surgery.”

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Comments

I read with disgust the opinions of Dr. Reeves in regard to Opioid Maintenance. It is sad that such a highly trained doctor in one field can allow himself to be so poorly educated in another. I'm not sure where he finds his information, but it was difficult to find anything that was accurate. His statements describing doctors who prescribe buprenorphine as being in the same category of "pill-mill" doctors, buprenorphine being a "good" drug for pain and being "greatly misused" are almost comical if it were not for the damage such statements could have on patients in recovery from opioid abuse. His discussion of methadone and buprenorphine implied that a patient must always be "weaned off" these meds in order to be successful. This demonstrates a fatal flaw in his "interpretation" of what addiction is and the lifelong struggle people have with their addictions. Shame on you Dr. Reeves. Stuff like this does more harm than good. In the future I would suggest that this publication would at least publish information that would correct the misleading errors made in this article before putting it in print

I practiced in a specialty for many years that demanded every decision be faced with knowledge of the highest grade evidence available or an outcome that was less than the best available would be achieved. I assure you, my method of practice that is supported by the best evidence available has not changed since I began practicing Addiction Medicine. Any “interpretation” I have of the disease of addiction is well supported in properly done high grade research in addition to my own experiences.
I stand by my statement about 98% of suboxone prescribing doctors. I should not have used the term “pill mill” however, as this implies a judgment of these doctors. It was a context answer during a question and answer session. What I will unequivocally state is that 98% of prescribing doctors may be very well trained and very well intended physicians, but they know little about treating addiction as a disease so an evidence based attempt at doing so cannot even be made.
Buprenorphine is in fact the “good medicine for pain” that you question. I have used buprenorphine as a perioperative pain medicine for many years before it was approved to treat addiction. Also evidence supported is the fact that buprenorphine is 30 times more potent than morphine as a pain reliever. Further, because of its agonist/antagonist activity, it promotes far less tolerance in pain relief than any full agonist opiate. Concerning it being “greatly misused”, one only needs to be marginally aware of the amount of buprenorphine on the street that is being diverted, and the rapidly rising number of people presenting for treatment for addiction to buprenorphine (not dependence, wide open addiction). No one is robbing Suboxone factories, it is all coming from doctors. Doctors do have a responsibility in this disease to hold patients accountable for proper use of prescribed medicines, not prescribe too much, and take measures to ensure these things.
Addiction is a disease, and it is a lifelong disease. Although many choose to debate these facts, the evidence is overwhelming. Once the genetic “switch” that Dr. Thomas Mclellan often describes has been activated, it cannot be undone. A person with Diabetes can be well managed to the point of showing no evidence of the disease. If that person does not continue to do the things that were done to achieve that healthy status, it will not remain. Exactly the same is true for Addiction.
This brings me to the real gist of your reply. Harm reduction verses Abstinence. That debate would take volumes, so I will clearly state my philosophy and opinion that is as evidence based as possible. Yes, with lifetime maintenance on methadone or buprenorphine or other substitute achieves positives. There is less hepatitis, less HIV, less crime, and fewer ER visits. These well documented benefits are societal benefits, and cannot be discounted. Unfortunately, societal benefits have been accepted as "enough" and individuals are not treated. There are no high grade studies showing what happens to individual patients in a longer time frame, say greater than one year. There are only some poorly controlled studies of populations. There does exist, however, much evidence of the long term negative effects on many neurotransmitters, brain circuits, and brain tissue of those maintained on these medicines. These abnormalities all have devastating and continued long term effects on quality of life. Recovery of these systems is not possible when the affected areas continue to receive substances that affect them negatively.
I had to ask myself in sorting out the facts, the literature and my own experience, what is my goal in the treatment addiction? Am I a Public Health Officer or an advocate of the individual in front of me. Will I be satisfied at helping someone get a job and spread less disease, or is my goal to help that person reach his/her full potential as a deserving full participant in humanity. We give up way too easily, in my opinion, settling for “improved” based on someone’s definition rather than to continue to push and seek and demand from ourselves better answers and better treatment. Settling for less than optimal because “so many fail anyway,” or “it simply costs too much” is not the answer my patients are seeking when they ask me for help. We allow our patient’s to believe there is no better way, so why would they do the work necessary to really find the place that is truly free from the prison of addiction. We must do better. Accepting long term substitute therapy is simply quarantining them to a place that causes less harm. Why is this acceptable to us? Maybe it helps them improve physically and socially in some ways, but does not help them achieve what I strongly believe and real evidence supports is available to everyone with this disease- true freedom from disease, true awareness of their own potential, and real optimism at the thought of reaching that potential. I cannot be satisfied with where we are today in the treatment of this disease, and I refuse to accept any treatment just because “I’m better than I used to be.” I have seen too many miracles in those that were previously given up on, even by professionals.

Thanks you for your ideas Dr. Reeves. I cannot reply to your lengthy reply on a point by point basis- it would simply take too long. It seems like it took a long time to justify what you had originally stated in your article. The 98% thing is amazing to me. It is a number you just pulled out of a hat ? Do you include yourself in this number? You refer to using evidence-based data, yet refuse to consider the evidence-based success of long-term therapy with buprenorphine. The bias you exhibit does not help your case. The disease of addiction lasts a lifetime. It is a bit presumptuous of some to assume that they know it all and can correctly identify the exact right therapy for each individual. Your discussion on buprenorphine being highly effective for pain and its potency vs. morphine should tell us that bupe is used more than morphine, oxycodone and other potent opioids, yet it is not. Knowing it has limited usefulness due to its ceiling effect and its tight binding to the mu receptor complicates switching to another opioid probably had something to do with it. Most people never even heard of buprenorphine before DATA 2000. "According to most studies", when buprenorphine is abused it is used to prevent withdrawal symptoms and not to get high 90-95% of the time.Lastly Dr. Reeves, I would ask you to consider what your patients see as being helpful to them on an individual basis and not your personal biases and opinions.
I really don't mean to be so confrontational. I think that you are likely an excellent doctor who tries to help those with addiction. We are on the same page when it comes to helping these individuals. Without help, I probably would have died 21 years ago when I was going through my addiction to opioids. I am grateful to those who helped me. I am glad that I could recover without maintenance (Buprenorphine maintenance did not exist in 1993)but after seeing how it is helping those in South Carolina, I think it could have been helpful then as it is now.I hope we can all move forward, work together and offer help to those who need it in whatever shape this help is available to us. Good luck to you and your Center.
Billy