Opioid Maintenance Therapy Saves Lives

It's important to note the context of this finding. When your options are sub-optimal treatment, no treatment, or opioid maintenance, opioid maintenance saves lives. Findings like this get published, and we learn that, in the context of crappy options, which option is the least crappy. This option gets categorized as "the best option" or as an evidence-based practice. No one stops to suggest that, maybe, we should change the context.

Opioid-dependent patients are 13 times more likely to die than their age- and sex-matched peers in the general population. To examine predictors of long-term mortality, Australian researchers conducted a 10-year follow-up study of 405 heroin-dependent patients who had participated in a randomized trial comparing methadone and buprenorphine.

• Overall mortality was 8.8 deaths per 1000 person-years of follow-up (0.66 during opioid maintenance treatment and 14.3 while out of treatment).
• Each additional opioid maintenance treatment episode lasting more than 7 days decreased mortality by 28%.
• Subjects who were using more heroin at baseline had a 12% lower mortality rate overall, likely because they spent more time in opioid maintenance treatment.

Comments:
Often overlooked in the controversy over opioid substitution therapy is the reality that opioid dependence has a high fatality rate. The current study highlights that opioid maintenance treatment saves lives. The selection of the treatment episode as greater than 7 days strongly suggests that opioid maintenance, not detoxification, reduces mortality. The time is right to promulgate opioid maintenance therapy with either buprenorphine or methadone as the standard-of-care, first-line treatment for opioid dependence.
Peter D. Friedmann, MD, MPH

Reference:
Gibson A, Degenhardt L, Mattick RP, et al. Exposure to opioid maintenance treatment reduces long-term mortality. Addiction. 2008;103(3):462–468.