[Commentary] WHY WE DO WHAT WE DO—DELIVERY OF BUPRENORPHINE AND THE TREATMENT OF OPIOID ADDICTION

At first glance, there is nothing unusual about the article by Bell and colleagues [1]. The Introduction notes that 'there is limited evidence of the effectiveness of maintenance treatment without observed dosing'. One simply assumes that the authors were interested in seeing how unobserved administration of buprenor-phine compares with the traditional way of doing things—whether patients will do as well. I was surprised , therefore, to read the authors' hypothesis that 'retention in treatment would be superior in the group randomized to unobserved dosing, as the requirement to attend a clinic for supervised administration of medication would be a deterrent to remaining in treatment'. What are they saying? Are they asserting that the way we have been treating patients is not in their best interests and that clinic attendance may actually be a deterrent to remaining in treatment? What the authors postulate appears to go against the long-standing precept that 'more is better' in terms of more services, treatment and clinical supervision being better in terms of longer retention, reduced drug use and improved functioning [2–4]. Most researchers and clinicians would presume that the group attending clinic more often for observed dosing would do better [5]. A lunch-time informal survey by showing of hands among investigators at the UCLA Integrated Substance Abuse Programs showed that the overwhelming majority (13 : 1) felt that way; a lone cynic thought patients might learn bad habits from other patients at the clinic. As it turned out, the two groups performed 'strikingly similar' in clinical outcomes, except that the cost for the unobserved group was, as predicted, significantly less. At this point, we could expect the authors to suggest that we should reconsider our current treatment approach, to grant greater latitude and reduce requirements for clinical contact. I was even more surprised when I came upon the first sentence of the discussion: 'Refuting the trial hypothesis, attendance for observed dosing was not a deterrent to remaining in treatment during the first 3 months.' What we have been doing so far is not so bad after all—perhaps we do not have to revamp our treatment approach. However, adherents to conventional addiction medicine could hardly take comfort in the outcome of the study and the way the results were framed in the treatment context. In the United States and in many other countries the idea of requiring clinic attendance has always been thought of as contributing …