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Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j1550 (Published 26 April 2017) Cite this as: BMJ 2017;357:j1550

Time to avoid inaccurate terms in this field: it's not substitution, it is opioid agonist treatment

Opioid agonist treatment is not "substitution." Reporting in the lay press is often sensationalist and inaccurate. But in a leading medical journal accurate non-stigmatizing medical terminology should be preferred as it influences how clinicians and policymakers view the disease opioid use disorder.

Illicit heroin and other opioid use produce euphoria and endocrine derangements, and the substances are used compulsively. However, when treatment is given with opioid agonists, there is no euphoria, homeostasis returns and the medications are taken regularly without compulsion, under medical supervision. And these treatments reduce mortality as randomized trials have found (and as have observational studies such as this most recent one).

Unfortunately a major barrier to dissemination of these treatments has been public and even addiction treatment professional misconceptions that opioid agonist treatment is somehow "substituting one drug for another." Such misconceptions lead to ignoring the large effect sizes on clinically relevant outcomes like abstinence (from illicit drugs), HIV transmission, overdose and death. The media fuels these misperceptions and it impacts patients, families, quality of care and access to it, and policies. It is time for leading medical journals to lead in the use of accurate terms that do not promote misconceptions. One problem of course is that the World Health Organisation persists in using the term and even goes farther describing the treatment as "replacement." (1) The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) uses the term, which is unfortunate since they produce excellent materials on substance use for the European community (2). Even the editorialists misused the term in the title of the accompanying editorial to this paper though they quickly pointed out the preferred term in the text (citing a Lancet editorial that called for retiring the term, written (some irony) by one of these same editorialists)(3,4).

What should be substituted and replaced, as was recommended in the Lancet 2 years ago, is the misnomer term "substitution." (3) The preferred term is opioid agonist treatment. Or more generally medication treatment. Or medication for addiction treatment. Or just buprenorphine and methadone.

1) http://www.euro.who.int/__data/assets/pdf_file/0015/241341/How-to-improv...
2) http://www.emcdda.europa.eu/topics/pods/preventing-diversion-of-opioid-s...
3) Samet JH, Fiellin DA. Opioid substitution therapy—time to replace the term. The Lancet , Volume 385 , Issue 9977 , 1508 - 1509.
4) Manhapra A, Rosenheck R, Fiellin DA. Opioid substitution treatment is linked to reduced risk of death in opioid use disorder. http://www.bmj.com/content/357/bmj.j1947

Competing interests: Vice President, International Society of Addiction Journal Editors, coordinating committee member International Network on Brief Interventions for Alcohol and Other Drugs, Burroughs Wellcome Fund, Alkermes provided mediation for an NIH funded study, National Institutes of Health (NIH), Department of Veterans Affairs, Editor of Journal of Addiction Medicine, Associate Editor JAMA, Editor and author for UpToDate and the American Society of Addiction Medicine Principles of Addiction Medicine, editor of Evidence-Based medicine last year, consultant to numerous non-profit health care (Kaiser Permanente) and health professional education and research institutions.

28 April 2017
Richard Saitz
Professor and Chair, Department of Community Health Sciences
Boston University School of Public Health
801 Massachusetts Avenue, 4th Floor