This is the area where the gap between what the research shows and what the treatment industry sells is widest — and it is worth understanding before you choose a programme, because a facility’s position on medication is a decision being made on your behalf.
The opioid findings are stark
Wakeman and colleagues (2020) followed 40,885 insured Americans with opioid use disorder and compared what actually happened under six different treatment pathways.
Treatment with buprenorphine or methadone was associated with a 76% reduction in overdose at three months and a 59% reduction at twelve months.
The uncomfortable half of that finding is what else they measured. Detoxification, intensive behavioural health treatment and naltrexone were not associated with any reduction in overdose — at three months or twelve.
Read that again with a brochure in your hand. The thirty-day residential detox that most families picture when they think of “getting help” did not, in this cohort, reduce the thing most likely to kill the person they love.
How long someone stayed on medication mattered enormously:
| Time on buprenorphine or methadone | Had an overdose |
|---|---|
| 1–30 days | 6.4% |
| 31–180 days | 3.4% |
| More than 180 days | 1.1% |
Short courses are not a gentler version of the same treatment. They are a substantially weaker one.
Mortality, not just relapse
Sordo and colleagues (2017) pooled cohort studies to measure something blunter: whether people die.
Time in opioid substitution treatment with methadone was associated with an average reduction of 25 deaths per 1000 person-years. The all-cause mortality rate during treatment was less than a third of the rate out of it, and the largest part of that difference was overdose deaths.
There is a detail in that paper which matters practically. Risk is not spread evenly. Mortality is much higher in the first four weeks of treatment than across the rest of it, and higher again in the first four weeks after leaving. Both transitions are dangerous, and the second one is the reason the weeks after a discharge deserve the attention this practice gives them.
Alcohol: real, modest, worth having
The alcohol picture is less dramatic and easier to describe honestly.
Jonas and colleagues (2014) pooled 122 randomised trials covering 22,803 people. Expressed as the number of people you would need to treat for one additional person to avoid returning to drinking:
- Acamprosate: 12.
- Oral naltrexone (50 mg/day): 20 for any drinking, and 12 for preventing a return to heavy drinking.
A number needed to treat of 12 means eleven people out of twelve get no detectable benefit on that measure. That is not a cure. It is also better than most things offered for most chronic conditions, and it costs very little.
Compared head to head, the two medications showed no statistically significant difference. Choosing between them turns on dosing, side effects and availability — not on one being superior.
What this should change about how you choose
Ask directly whether medication is available, and what the facility’s position on it is. A programme with a philosophical objection to buprenorphine is making a consequential decision for your family member. You are entitled to know it is being made.
Treat a short medication course as a short medication course. If the plan is thirty days on buprenorphine and then off, ask what the evidence is for that particular length. The duration data above does not support it.
Plan hardest around the two transitions. Starting treatment and leaving it are the highest-risk windows in the whole sequence. That is precisely where structured support belongs, and it is the reasoning behind how our case management work is scheduled.
The honest caveats
These are observational cohort studies, not randomised trials — people who stay on medication for a year differ from people who do not, in ways that also affect outcome. The effect sizes are large enough and consistent enough across studies that this is unlikely to explain them away, but it is a real limitation.
None of this says medication alone is sufficient, and the research does not claim it. It says that leaving it out, for opioid use disorder in particular, removes the single intervention with the strongest evidence of keeping someone alive.
References
- Wakeman SE, Larochelle MR, Ameli O, et al. (2020). Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder. JAMA Network Open. 10.1001/jamanetworkopen.2019.20622
- Sordo L, Barrio G, Bravo MJ, et al. (2017). Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ, 357, j1550. 10.1136/bmj.j1550
- Jonas DE, Amick HR, Feltner C, et al. (2014). Pharmacotherapy for adults with alcohol use disorders in outpatient settings. JAMA, 311, 1889-1900. 10.1001/jama.2014.3628
- Ma J, Bao YP, Wang RJ, et al. (2018). Effects of medication-assisted treatment on mortality among opioids users: a systematic review and meta-analysis. Molecular Psychiatry. 10.1038/s41380-018-0094-5
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