Morning Zen

Socrates Junior Inquires About Medically Assisted Treatment

August 11, 2018

Enjoy this Morning Zen post about a mythical protagonist named “Socrates Junior,” who is on a quest to make sense out of recent decisions by SAMHSA to abolish the National Registry of Evidence-Based Programs and Practices (NREPP). The post was written by a research scientist who has asked to remain anonymous. 

My teacher, Socrates, was always getting into trouble asking about what is true. Ultimately, he miffed the high and mighty so much they made him drink poison for unmasking their arrogance and folly. A few years ago, there was much ado by the Treatment Advocacy people, then Congressman Murphy and others attacking SAMSHA for the lack of pharmaceutical treatments on the National Registry of Evidence-Based Programs and Practices. Big Pharma was being bullied and, worse still, ignored by the National Registry of Evidence-Based Programs and Practices (NREPP).

And, now there will be the great and wonderful Policy Lab to elevate medically assisted treatment led by the Assistant Secretary who has many publications on medically assisted treatment for addictions. The Assistant Secretary has very high disdain for other people’s science, perhaps because of the exceptionally high number of medical articles published by the Assistant Secretary. She has at least 107 publications in the National Library of Medicine according to Socrates Junior who looked her up.

Socrates Junior, who takes after his father in unconventionality, wondered how many of those publications were randomized trials. He wanted to ask Assistant Secretary personally, but it’s difficult for people who look scruffy and homeless like Socrates Junior to get past security. So Socrates Junior went to a public library to use a computer like a lot of homeless people.  Socrates Junior wondered how many of these papers by Dr. McCance-Katz where randomized-control trials (the gold standard, especially for pharmaceuticals like medically assisted treatment for addictions).  Socrates’ said his computer search suggested 19 of Dr. McCance-Katz’s studies were randomized trials. Table 1 includes what appears to be the randomized trials by Dr. McCance-Katz.

Then, Socrates Junior asked some other scientists to review these for how earthshaking the studies were, and the other scientists said these are mostly lab studies—not real treatment studies. Real treatment studies ought to be done in the real world, with real patients with long-term follow up to look at relapse rates. That’s typically called a “survivor analysis.”

Additionally, great the trials ought to be comparative effectiveness studies, with matched random assignment, testing different combinations of treatments plus control/treatment as usual with one or more years of follow up. Socrates Junior asked the Cochrane Library what they thought about medically assisted treatment regarding science. The Cochrane Library guards the Temple of Science.  Cochrane makes it clear that without psychological/behavioral treatments, pharmacological detoxification treatments (medically assisted treatment in the new name) have little lasting effects [1].  Further, Cochrane reviews conclude:

  • In 2010, “There is low evidence, at the present, supporting the clinical use of antidepressants for the treatment of depressed opioid addicts in treatment with opioid agonists” [2].
  • In 2011, “At the current stage of evidence data do not support the efficacy of antidepressants in the treatment of cocaine abuse/dependence.” [3]
  • In 2010 for a different medication, “There is low evidence, at the present, supporting the clinical use of disulfiram for the treatment of cocaine dependence. Larger randomized investigations are needed investigating relevant outcomes and reporting data to allow comparisons of results between studies.”
  • In 2011 for the use of dopamine agonists (meds that increase dopamine) [1], “Current evidence from randomized controlled trials does not support the use of dopamine agonists for treating cocaine dependence. This absence of evidence may leave to clinicians the alternative of balancing the possible benefits against the potential adverse effects of the treatment. Even the potential benefit of combining a dopamine agonist with a more potent psychosocial intervention which was suggested by the previous Cochrane review (Soares 2003), is not supported by the results of this updated review.”

After reviewing the Cochrane search report, Socrates Junior asked a profound question: “Who benefits by medically assisted treatment that seems to have no benefits or even, quite possibly, iatrogenic effects?”

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About the Author

Socrates Jr.

Socrates Junior is on a quest to make sense out of recent decisions by SAMHSA around how to define evidence-based practice. 

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