Opioid replacement treatment. Great! What’s next?
In opioid use disorder treatment, there’s been a persistent (though not always acknowledged) tension between what’s good for public health and what individuals and their families want from treatment. I’ve written about it before. For public health, there’s plenty of evidence that MAT (medication assisted treatment) reduces illicit drug use, improves health and reduces crude mortality rates.
There can’t be many people in Scotland who wouldn’t agree with the importance of the prioritisation of saving lives and reducing physical and mental health harms as a first response to a life-threatening condition.
Titrating a person with an opioid use disorder onto replacement therapy was usually my first suggestion to them when I worked in community clinics. It would again be if I were to go back to that setting – though it wouldn’t be my only suggestion. In Scotland where we have a shameful level of drug-related deaths, MAT needs to be our first step for those with opioid use disorder in most cases. But then the question ought to be: ‘what’s next?’ because patient-important outcomes need to be addressed alongside public health priorities.
This week, in an online meeting of treatment providers, we heard stories of those who wanted to move on from MAT, but who were blocked in various ways from doing so. Their prescribers had refused to lower their dose or refer them to rehab. The reason that was most commonly given was ‘it’s too dangerous’. But we also heard more encouraging stories of personal choice helped by high level support, connection to mutual aid, flexible reductions in dose with close monitoring, early re-titration where necessary and referral on to residential rehab with good long-term outcomes.
I absolutely understand the risk element and the fears that exist of destabilisation and relapse. These are legitimate. But there are four questions worth thinking about here.
- What do individuals and their families want?
- Is it what’s on offer?
- Can people move on safely?
- If so, how do we mitigate risks?
Meeting people with opiate use disorder who were in long term abstinent recovery from illicit and prescribed drugs changed my mind about what was possible. I suppose I have met hundreds of such people over the years. That’s a game changer. I worry that some prescribers don’t spend enough time with people in recovery.
Although there are substantial benefits to MAT, there are also problems: non-engagement with those who would benefit and timely access for instance. Then there are other issues too: stigmatisation of those on methadone, poor retention in treatment and how MAT fits in with the management of problem polysubstance use, including alcohol.
Some of these challenges are related to treatment delivery and can be improved. Indeed, there is much work going on in Scotland at the moment to address some of these through the MAT standards. MAT is a vital weapon in the battle against drug deaths – in that sense a major public health intervention – however, in community clinics we deal not with the public en masse, but with individuals whose own goals will sometimes clash with the public health imperative.
So, does MAT help patients achieve their wider goals – those person-important outcomes? We don’t really know is the short answer. A systematic review published in 2017, found that health related quality of life measures are rarely used as outcomes in MAT research. When looked at from a recovery perspective, we have more evidence on the negatives that go than on the positives that arrive. There are studies showing improved quality of life, but we need more on whether people reach their goals and get improvements in the things that matter to them.
A small in-depth Norwegian study involving 7 women and 18 men on MAT found evidence of them being ‘stuck in limbo’ in terms of not moving on despite national guidance that the patient’s own goals ‘should be the basis of treatment’. These drug users were still engaged in illicit drug scenes. The researchers found four themes:
- Loss of hope
- Trapped in MAT
- Substitution treatment is not enough
- Stigmatisation of identity
Some of this will chime with service users here too, though I see such themes as systemic issues rather than a problem with MAT per se. We can address some of this through the introduction of hope at every encounter – from safe injecting spaces to residential rehab, and if we can get recovery-oriented systems of care operational, have nobody ‘trapped’ anywhere in our services.
Another Norwegian study found that health-related quality of life for those on long term opiate replacement therapy was significantly lower than the general population – indeed lower than that of those with severe mental and physical health conditions.
Recognising these issues, a major review has been announced in the British Medical Journal, which moves away from public health-important outcomes to look at patient-important outcomes. The researchers state:
“Recent guidelines indicate there is little consistent evidence to evaluate the effectiveness of MATs [Medication assisted treatments]. Reviews evaluating MAT effectiveness have found great variability in outcomes between studies, making it difficult to establish a real treatment effect.
Each study measures a different set of treatment outcomes that define success in arbitrary or convenient terms. This is a substantial limitation in addiction research that must be overcome to reach a consensus on which treatment outcome domains should be the goals, how those outcome domains should be measured and what works for opioid addiction management.
If the outcome for such trials was reduced criminal activity, reduced incidence of infectious diseases, reduced homelessness or other social advantage, the intervention may be helpful for only certain groups of patients.”
The editor of the Journal Drug and Alcohol Dependence, Eric Strain, takes up the same theme this month in an editorial. My co-contributor, Jason has covered this in more depth recently. While making the point that reducing loss is undoubtedly a ‘worthy goal’, But Strain talks about the risk of stopping there. He says:
Efforts to address this have resulted in a focus on decreasing overdose deaths as an endpoint
He makes the point that setting a numerical goal for death reduction means it can be celebrated when achieved. He says, ‘it is worrisome and problematic to think that decreasing the percentage of opioid overdose deaths will solve the problem of opioid use. For patients and their families, it will not.’ He goes on to say:
Not overdosing is an insufficient endpoint for treatment or for societal and medical interventions – it’s a starting point.
Strain talks about the importance of finding meaning and purpose and allowing people to ‘flourish’. He points out that researchers and healthcare providers see these as critically important in their own lives, yet we don’t seem to prioritise these for patients or in research.
I’m glad that quality of life is being taken more seriously by researchers. Recovery research has focussed on this for years, and rightly so, because quality of life is important to the people we are working with and to their families. There are other important things to be explored. We need research to understand what works best to reduce risks to those seeking abstinence, to explore what part our treatment systems play in facilitating and blocking people moving on, and to understand long term outcomes in those choosing abstinence/recovery pathways (where they exist).
There will be many people who are satisfied with where they are in terms of treatment, including those on long term MAT. If they have been given meaningful choice in our treatment system and chosen MAT, then that’s cause for celebration. I’m thinking of those who have different goals and how we might improve what’s on offer to help them.
The question ‘what’s next?’ is a crucial one if we are to accept that reducing drug deaths is a necessary start but not an end in itself. We have to navigate the dual goals of reducing drug deaths and helping people flourish. These needn’t be in opposition; indeed, many will say that harm reduction interventions saved their lives and allowed them to recover.
I’ll leave you with two other questions. Is that question ‘what’s next?’ being asked enough, and are there safe and supported routes available to help people reach their own important outcomes?
Continue the discussion on Twitter @DocDavidM
 Bray JW, Aden B, Eggman AA, et al. Quality of life as an outcome of opioid use disorder treatment: A systematic review. J Subst Abuse Treat. 2017;76:88-93. doi:10.1016/j.jsat.2017.01.019
 Grønnestad TE, Sagvaag H. Stuck in limbo: illicit drug users’ experiences with opioid maintenance treatment and the relation to recovery. Int J Qual Stud Health Well-being. 2016;11:31992. Published 2016 Oct 19. doi:10.3402/qhw.v11.31992
 Aas, C.F., Vold, J.H., Skurtveit, S. et al. Health-related quality of life of long-term patients receiving opioid agonist therapy: a nested prospective cohort study in Norway. Subst Abuse Treat Prev Policy 15, 68 (2020). https://doi.org/10.1186/s13011-020-00309-y
 Sanger N, Shahid H, Dennis BB, et al, Identifying patient-important outcomes in medication-assisted treatment for opioid use disorder patients: a systematic review protocol BMJ Open 2018;8:e025059. doi: 10.1136/bmjopen-2018-025059
 Eric C. Strain, Meaning and purpose in the context of opioid overdose deaths, Drug and Alcohol Dependence, Volume 219, 2021,