Evidence for the Effectiveness of Opioid Agonist (Suboxone & Methadone)

NOTE: This webpage consists of an excerpt from Chapter 9 of the book

Outcomes:   Pros and Cons

The goal of treatment for most chronic diseases is not cure but control; to minimize the harms from the disease (see Chapter 11). While the ultimate goal might be total control, or remission, the immediate goal is to prevent the harms from the disease. Thus, the goal of diabetes treatment is not to cure the disease but to control blood sugars to prevent organ damage from the disease. The better we control diabetes, the lower the risks will be of complications such as heart attacks and strokes, kidney damage, retinal damage, nerve damage, loss of circulation to the lower limbs, or death. 

We can divide benefits of medical treatment of opioid addiction into four categories: Mortality (death rates), morbidity (health and suffering), social/societal benefits, and improved functioning. Let’s see how well medical management of opioid addiction stacks up in each of these categories. We will focus on the data for methadone clinics, but the data for buprenorphine is similarly impressive.

Mortality (Death Rates)

Clinical studies on the use of buprenorphine or methadone for opioid addiction consistently show that both these medications reduce all-cause mortality by roughly 50%. All-cause mortality means deaths from any cause, including not only overdoses but also deaths from impaired driving, complications of drug use (heart valve infections, hepatitis, seizures, etc.), suicides, and deaths unrelated to the addiction. 

As mentioned in the previous chapter, it is not enough to look for beneficial results; we must also consider harmful results. In other words, we must balance the “pros” and “cons.” Concerns about methadone are justified because methadone can be abused on the streets, causing fatal overdoses. However, all-cause mortality automatically takes into account deaths caused by methadone as well as lives saved by methadone. 

How does 50% reduction in all-cause mortality compare to medical treatments for other medical conditions? A good comparison would be the treatment of heart attacks and strokes, which also represent conditions with relatively high mortality rates. There are three classes of medications commonly used to lower mortality from cardiovascular diseases: cholesterol-lowering drugs known as statins, blood pressure-lowering drugs, and low-dose aspirin. Of these, cholesterol-lowering statins, such as atorvastatin (lipitor), are the most effective at preventing deaths from heart attacks and strokes. Statins reduce all-cause mortality (deaths from heart attacks and strokes related to high cholesterol as well as unrelated deaths from cancer, car accidents, etc.) by about 28%. Blood pressure medications lower mortality by less than one-quarter. The benefits of low-dose aspirin are questionable, especially for people over the age of 50. Aspirin has trouble showing reductions in all-cause mortality because reductions in cardiovascular deaths are offset by increased deaths from kidney disease and bleeding ulcers. 

The effectiveness of medical opioids for reducing mortality is vastly superior to the effectiveness of cholesterol-lowering statins, blood pressure medicines, and aspirin. In fact, medical opioids are among the most effective medications we have in the entire field of medicine. Some people might think we are comparing apples to oranges, but we are not. We are measuring “all-cause mortality” in both situations. It would be comparable, for example, to comparing on-the-job death rates for police officers versus electricians. 

Buprenorphine and methadone are undeniably life-saving medications. 

Morbidity (Health and Suffering)

Diseases do not just kill people, they also cause a lot of suffering through poor health. The suffering associated with diseases is known as morbidity. Morbidity and mortality are related but they are not the same. Pneumonia can kill if severe enough but it can also cause a lot of suffering (shortness of breath, fatigue, fever, etc.) in those who do not die. 

Medical opioids reduce fatal overdoses. They also reduce cases of non-fatal overdoses. Non-fatal overdoses can cause permanent damage to the brain and other nervous tissue, muscle and kidney injury, and other injuries from the lack of oxygen. Medical opioids have also been proven to reduce complications of drug use, such as Hepatitis C, HIV, heart valve infections, sepsis, infections, etc. These complications are major sources of morbidity. When severe enough, these complications can kill, at which point they show up in that first category of all-cause mortality. 

In short, medical opioids do not just reduce deaths, but they also improve the health and quality of life of opioid addicts. 

Social & Societal Benefits

Opioid addiction is harmful not only to addicts but also to society and communities. Buprenorphine and methadone treatments have both been shown to reduce crime rates, arrest rates, probation violations, and incarceration rates. For opioid addicts, these treatments translate to lower rates of new arrests and incarcerations.

There is almost always a public outcry when a new methadone clinic is proposed because neighborhood citizens are concerned it will attract crime. However, studies find crime rates actually drop in the neighborhood of methadone clinics after the clinic opens. 

Other societal benefits include reducing the public burdens of healthcare costs, the costs of law enforcement and the criminal justice system, and other expenses paid by taxpayers. Intravenous drug users cost the healthcare system a lot of money; from ICU beds to cardiac surgeries for heart valve infections, to treatments for Hepatitis C and HIV. Since a large segment of addicts has trouble holding down jobs, these costs are passed on to the public purse, in the form of Medicaid or Medicare. Medical opioid treatments result in significant healthcare savings due to lower rates of overdoses, transmission of Hepatitis C and HIV, heart valve infections, etc. Fewer arrests and incarcerations reduce burdens on the criminal justice system (incarcerations cost taxpayers over $30,000 per inmate per year).  

Improved Functioning

Lastly, opioid addicts treated with buprenorphine or methadone show improvements in their social functioning and well-being. I have had many patients reconcile with their families and some who regained custody of children removed by Child Protective Services. They are able to hold on to jobs, become productive members of society again, and start paying taxes. They are able to save money for cars, vacations, and everything else other citizens enjoy. They go back to school and build new lives and new careers. As I mentioned in the Preface, it was witnessing this kind of miraculous transformation that inspired me to shift careers to become an addiction physician. 

You do not have to take my word for this sort of transformation. Simply pick up a phone and call any methadone clinic. You will find that practically every methadone clinic in America opens its doors between 5:00 and 5:30 am. How many other medical facilities open their doors that early? The only reason methadone clinics open that early is because patients receive their treatment before going to work. Methadone clinics would not need to open early if they were not restoring at least some of their patients to gainful employment.