Let us hope that the frequent framing of pharmacological treatments as the only evidence-based approach doesn’t eclipse the evidence for behavioral and social interventions like sober housing:
Following substance abuse treatment, individuals who live in a collaborative housing setting with community rules and responsibilities have their substance abuse treated more effectively than those not provided supportive housing, according to research led by Leonard Jason, a community psychologist at DePaul University.
Research shows that living in a functional community and engaging in positive social structures enhances the recovery trajectory for alcohol and drug abuse, noted Jason, director of the Center for Community Research at DePaul.
Leonard’s research also provides insight into some of the characteristics of successful sober houses and their benefits:
According to Jason, in order for the Oxford Houses to be the most effective in treating its residents, it is best if they are located in safe neighborhoods or strong communities. “Based on our research, the houses work best when they are close to public transportation, have job opportunities, and have other supports such as AA self-help groups. We also have data showing that Oxford House residents do contribute and strengthen their neighborhoods,” Jason said. “Our research shows that it is a win-win situation, with communities benefiting from these Oxford Houses, and the support the Oxford House residents receive from their communities help these former substance abusers live more productive and healthier lives.”
recoveryreview.blog 
Jason, I appreciate the thought and consideration that you have put into your responses, however, I’d like to attempt to counter a few that I can cull from my subutex addled brain.
Repeatedly, you referenced that opiate dependent patients should have care “at least as good as physicians”. I shouldn’t put that in quotes, because I am paraphrasing but so it is noted. There is a vast difference between the care received in the physician diversion programs and the treatment received by most opiate dependent patients. If a physician falls out of the treatment process (established by their medical board), they lose an extremely valuable, tangible thing……their license to practice medicine, make a good living and do the thing that they spent seven years of their life slaving over. That, alone, separates the patients that we treat and the physicians that you allude to.
Unfortunately, you, also, fall into the, all or nothing, mindset. Perhaps, each patient is different, having differing tolerances for the acute and post acute withdrawal syndromes. A strategy that allows the patient to review different options of treatment strategy, gives the patient a sense of control and makes jcaho happy because it is patient centered. It is their life, right?! In our outpatient program, for 25 years, we adhered to the same abstinence based programming that I experienced in 1980. At that time, I had been a heavy sedative addict (methaqualone, barbiturates, benzos, alcohol etc.) and my withdrawal from benzos was a year long process of dealing with ongoing panic attacks and hallucinations. I was convinced that I was crazy until some kind doctor shared his similar story of coming off of valium. Now, fast forward to 2003 and I have shoulder surgery to repair rotator cuffs and assorted damage from 13 full contact benefit football games that I chose to participate in. Three months later, I was broadsided and tore everything loose that had been repaired. My options were more surgery with poor prognosis, frozen shoulder or take norco before daily stretching to increase range of motion and break up scar tissue. I chose the later, Never went over the prescribed dose of four per day and eight months later was ready to abandon the norco with a prudent taper. When I hit zero, I went into a depression, insomnia and inability to sleep that was devastating. As the director of a treatment program, I felt ashamed, hypocritical and had recurring thoughts of suicide that had never arisen in my benzo withdrawal. I lost thirty pounds, went to our home in Hawaii to do a slower taper with the same results. After forty five or more days, I had lost thirty pounds, slept maybe two hours per night and hated the meetings that had saved my life 26 years before. A pain management physician friend offered me the option of methadone for life and I asked him to tell me about buprenorphine. He was not certified, at the time, so wrote it off label and in 45 mins. I felt like the person who went into surgery. I could feel again the joy of life. I cried out of gratitude and sadness. It has been ten years and I continue to take about 4 to 8 mgs. of subutex and have found that I have never been healthier (I’m 67 scuba, fish Mexico, play softball, workout, tried MMA but my shoulder won’t allow it). I believe that the anti-inflammatory affects of the bupe and its anti cortisol action has allowed me to stay in extremely good condition.
I want to share one more anecdotal experience for you to consider as we have an aging population of addiction counselors who are, inevitably, going to be involved in surgeries and pain meds. A colleague, who was the first person I saw in treatment and who later became the director of some of the largest and most prestigious programs in the country came by to see me two years ago. I shared this story. He began to cry and I, of course, considered it for me. However, his response was, that is exactly what I have been dealing with for two years since my surgery. His drug of choice was opiates and the demon had awakened. I suggested that we cross the street and see my physician who could prescribe some bupe. He refused saying “if they find out at my employment, they’ll fire me”. A few days later he called and said get me the appointment “I just bought a gun in Vegas and texted my wife goodbye”. He started on the bupe that day. I get pictures of him at ball games with his boys and skiing with his girls. His statement is “I have my recovery back”. He and I and many others in recovery but on bupe, continue in our recovery. It has been ten years for me. I refuse to give up one more day to the soul sucking horror that is post acute withdrawal syndrome. I am not a pharmaceutical rep. with a new study. I run a full service outpatient program with my wife and daughter. She was awarded outstanding clinician of the year for nursing by Gary Enos et al. We have been awarded the Optum Impact Award for helping UBH establish safety protocol for ambulatory detox. All within the last five years. A day was named after my wife and I.
We use buprenorphine with our patients if, after a careful discusssion of the plusses and minuses, they and their families agree that they want to take that course. Each patient presents a different picture, thus a 19 year old’s plan will probably include a period of months on bupe to establish recovery connections while an older pain patient may have a different plan. But, it is their plan and nothing except a return to full agonists constitutes a relapse. We let them know that we are there if it gets tough and we can slow down or use other medications, more exercise, yoga, equine therapy etc. to assist in the reclamation of their sense of self. There is no one or two or a thousand answers. There are as many answers as there are patients. I know at the point that I was at in my life, this was and is the answer for me. I would be glad to talk to you my email is molokairock@aol.com.
Thanks for your contributions. We all make a difference.
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Rocky,
You’re right about doctors having a unique set of contingencies and the absence of these contingencies presents some significant challenges in transferring this model to other populations. What bothers me is that we’re not trying to transfer this model to others, the assumption that doctors are an entirely different species seems to go unquestioned, and this model is never even mentioned in discussions (media stories and policy discussions) about opioid addiction.
If this was cancer, and there was a model with research on large numbers of subjects experiencing an 80% recovery rate, we’d invest heavily in finding ways to use it with other populations. In our industry, we pretend it doesn’t exist or has no relevance to other opioid addicts. If dentists can find ways to keep patients coming over decades, we can develop ways to develop and maintain assertive recovery monitoring over 5 years.
About your impression that I have an all or nothing mindset. I’ll explain where I stand and let you decide if that’s an all or nothing mindset.
I want 2 things for every addict. The first is recovery. By recovery, I mean resuming (or beginning) stable and full participation in their life–family, occupational, community, social, spiritual, etc. Recovery is something to celebrate and I don’t care how an individual gets there. Further, I have no interest in labeling one as legitimate and another as invalid. (At the same time, as policy makers and treatment providers, I think it’s important to recognize that some paths offer large communities of support that enhance outcomes.)
The second thing I want for every addict is real access to good care of adequate quality, intensity and duration. I want the PHP model available to people AND a menu of other options, including MAT. I also want them to have accurate information about the pros and cons of each approach, and have the freedom to choose their path and change their mind down the road.
My most recent post on the topic of MAT said this:
In other posts, going back to the beginning of this blog, I’ve repeatedly said things like:
If there are posts that present an all or nothing mindset, let me know and I’ll add an update with one of those statements.
Best,
Jason
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Thanks for your rapid and thorough response. I would need to go back and review some of the comments that formed my opinion. Clearly, the information that you have shared, in this communication, puts us very close in our commitment to individualized treatment care plans for addicts in general. As I recall, you commented that you wished that all opiate dependent patients would receive the same care that physician’s receive and that they do not, universally (my add) obtain suboxone under any circumstances. Ultimately, a the impaired physician’s program, just like the California Nurses programs, adhere to a very firm abstinence only philosophy. That appears pretty all or nothing. I would question, why do we treat physicians differently, than the general population. Would you ever consider buprenorphine a viable alternative for a practicing physician.
Obviously, physician’s practice under the influence of psychotropic medications like prozac, zoloft etc. How does buprenorphine fit into another category. Yes, I know that it is a narcotic, but its actions are very different than full agonists.
From 2004 until a few years ago, I continued to be the CEO of our full service outpatient program. My RN wife and other staff, ironically, commented on how improved my mood had become and my ability to stay focused. Would you consider my position of relative influence over the lives of others to be potentially impaired because of my use of subutex? And, would this preclude, in your opinion, my ability to function optimally at my profession?
For the record, we are a licensed outpatient ambulatory detox facility with two nurses and multiple physicians, provide PHP, day and evening IOP and multiple family components. I agree with you that the patient deserves the right to weigh the information, and have input into their ongoing treatment planning. That is a basic tenet of our programming and has worked well for 28 years.
Thanks again for your response and a very good source of information.
Rocky
951-768-1222
http://www.hillrecovery.com
http://www.manifesttreatment.com
http://www.leaplaw.net
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I wish patients had ACCESS to the same care that physicians get.
All the best.
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I wish all patients had access to the kind of care that we have discussed. Evidence based, patient centered, family included and, preferably, community based. I remember when the conferences were headlined by the likes of Claudia Black, Sharon Cruse, Dr. Paul Ohliger, Lorie Dwitnnell etc. etc. Very little on ROI.
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