Counterpoint: detox provides a chance at long term remission for some. Buprenorphine/methadone much more rarely. Perhaps more akin to a choice between tamoxifen for life for breast CA vs. a one-time surgery?
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Detox alone means remission for almost no one. Of course we need to respect patient preference. But if said “one-time surgery” was associated with increased mortality risk and ~90% recurrence, would it be offered? “Detoxing” people from opioids is dangerous.
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Is there a long-term RCT comparing detox to agonist therapy? If so, then yes- bupe/methad should be standard of care, and detox should not be covered. Barring that kind of evidence, which is on us as the medical profession to obtain, who are we to demand that insurers cover it?
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Find here our Canadian guidelines that recommend against withdrawal management only. In BC, medications are now covered for everyone on social assistance and those making less than $42k/yr. though, still a long way to go here, too.http://www.cmaj.ca/content/190/9/E247 …
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There was a guideline that recommended all patients be given a beta-blocker prior to surgery. Became std. of care, anesthesiologists were penalized for not giving it. Then 10 years later, inc mortality. Where is the RCT? How is it that we are changing practice wholesale w/o one?
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There is a mountain of RCT evidence that those not on medication don’t do well in terms of relapse and retention. Mortality data won’t come from RCTs that are 3 months -12 months in length. RCTs plus observational data tell the whole story.
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Given all this, we should do a large RCT, if not before, then as part of a switch to MAT focused therapy, to truly know the harms and benefits of the drugs we are making standard of care.
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So you want to hold addiction medication to a standard the rest of medicine is not held to? Show me these trials for antidepressants, benzos, opioids for pain... And in an epidemic like this? Come on.
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In some areas of the country, accessing these therapies is difficult. In a study from our group of 4
#Appalachian states. Only half of providers took any insurance. Being pregnant/paying with insurance made it harder to get appt, longer wait. https://www.ncbi.nlm.nih.gov/pubmed/29949454 pic.twitter.com/AcfffURWm8
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Couldn’t agree more. Eliminate DATA 2000 requirement - increase access to Bupe instantly. We need more MAT, not just more “beds”
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Agreed. The best evidence we have available shows buprenorphine or methadone reduce mortality. Detox can decrease a person’s physiologic tolerance to opioids thus INCREASING the risk of overdose death in the event of relapse.
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Not saying NO one has benefitted from detox. Beyond the method chosen, patients’ success will depend on: -Reliable access to primary care -SW / Counselling/Education -Managing psychiatric comorbidities -Close follow up -Community/Family support -Love / Patience / Understanding
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Plus funding of medications! I believe "cure" will have to go far beyond the biomedical model.
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PCPs are why these people are addicted in the first place. I'm not saying doctors shouldn't be part of the solution but let's acknowledge they were part of the problem.
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Yes, they were culpable. But you won’t solve crisis w/o doctors on board. So time to move fwd
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Yeah sure but "let PCPs prescribe" is what got us here so it's not absurd to think another solution is viable.
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Up here in Ontario we combine detox and OAT, followed by OAT and residential treatment* Would never go back to detox alone, cause we don't want to kill people, we want to help them get well. *Not all treatment programs do OAT, but more and more do.
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Also would be great if insurance would pay for it without a protracted fight.
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BTW, in Germany. we have a substitution-program using methadon wich is quite successful.
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