This morning I saw a link on Twitter that surprised and discomfited me. “Buprenorphine and methadone shown to be equally effective in prison study,” read the tweet, along with this link to a study performed on opiate-addicted inmates in English prisons. I was a bit skeptical, since it has been my overwhelming experience that buprenorphine is far superior to methadone when it comes to helping opiate-addicted patients avoid relapse, stop taking opiates, and live their lives in normalcy. I wanted to know what evidence could possibly have turned up that might challenge what I had observed with my own eyes.
As it turned out, the study wasn’t anything new or surprising after all. The researchers concluded that buprenorphine was no more effective than methadone at helping addicted patients when both treatments were administed on a “tapering” schedule. According the summary of the study, “[d]etoxification was typically conducted over 20 days, tapering down from a five-day stabilisation dose of 30mg methadone or 8mg buprenorphine daily.” In the long run, neither medication was particularly effective; only 20% of the prisoners who could be retested were found to still be abstinent from substances 3 months after the end of the study.
It makes perfect sense that buprenorphine would be no better than methadone in a “tapering” protocol, because tapering does not work. No medication currently available to medicine will work particularly well in a tapering protocol. It is an uncomfortable but unavoidable truth that addiction, particularly long-term, high-dosage addiction, causes permanent damage to the reward systems of the brain. The extent of this damage differs in every patient, and in some patients it may improve, but once it has occurred it cannot be entirely reversed. Its effects can be mitigated with medication; this is the goal of treatment. To treat a patient with appropriate medications and then take them away after five days is, from a biological perspective, completely pointless; and it can also be cruel.
When the treatment is taken away, the damage is still there. The brain, while an infinitely complex and marvelous system, cannot always heal itself completely like, for instance, a broken arm can. The brain, when severely damaged, requires more than just a few weeks of temporary support to allow it to recuperate. The brain needs long-term, constant management to keep the reward system in a homeostatic balance that will allow the patient to best continue with their normal life.
For as long as medication for addiction has been available, doctors have been trying to use it as they would use a cast for a broken arm, hoping that if they just use it briefly and take it away, the damage will be gone. The fact is that this does not work, has never worked, and will not work in its current incarnation. The problem of addiction is chronic and must be treated chronically.
I was disappointed to find that we have not yet learned this, but hopefully the study linked above will help us take a step closer to that realization.