A New Paradigm for Substance Use Disorder Treatment

From Robert DuPont, MD:

Substance abuse treatment is committed to abstinence from nonmedical drug use. Yet, continued nonmedical drug and alcohol use and relapse are so common that they are often defined as part of the disease itself.

A “new paradigm” for care management has been pioneered over the past four decades by the state Physician Health Programs (PHPs).PHPs provide diagnostic evaluation, treatment referral, close monitoring and support services to health care professionals who have conditions, including in particular substance use disorders, which can impair their ability to practice medicine with reasonable skill and safety. In dealing with substance use disorders, PHPs use a zero tolerance standard for any alcohol or other drug use, enforced by intensive random testing and close linkage to the 12-step programs of Alcoholics Anonymous and Narcotics Anonymous to produce remarkable long-term outcomes. These outcomes set a far higher standard for success in treatment and they cast doubt on the definition of addiction as being characterized by relapse. They demonstrate that the environment in which the decision to use or not to use alcohol and drugs is a powerful determinant of outcomes.


While some may dismiss the PHP results because physicians are a uniquely advantaged patient population, a similar approach has produced outstanding results in a dramatically different population of addicted people — convicted felons on probation. A randomized control study of the pioneering HOPE Program showed that compared to a control group of standard probationers, HOPE participants were 55 percent less likely to be arrested for new crimes, 72 percent less likely to use drugs, 61 percent less likely to miss appointments with probation officers and 53 percent less likely to have their probation revoked.3 HOPE probationers were sentenced to 48 percent fewer days of incarceration.

The new paradigm of long-term monitoring with swift, certain and serious consequences for any detection of drug or alcohol has the potential to substantially improve long-term outcomes for substance abuse treatment.

Now, I’m not interested in a paradigm that makes consequences a central element.

However, what’s important here is that there is a very effective treatment for this chronic illness and, like most treatments for chronic illnesses, we struggle with engagement and compliance. In the case of addiction, why do we respond to those struggles with a lowering of the bar?

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