What’s with all of the posts about methadone and buprenorphine?

I’ve been doing a lot of posts on methadone and buprenorphine lately. It’s not that I think they are evil and should be banned.

It’s just that, if your knowledge was limited to what’s in media reports, you’d believe that medications like buprenorphine and methadone are the only responsible treatment, that they are inaccessible, and that any abstinence-based treatment is dangerous and only advocated by flat-earth zealots.

There’s evidence to support the use of these meds. But, the evidence is not as strong as many would lead readers to believe, and most of the studies do not measure the kinds of outcomes that addicts and their families are looking for.

So, these posts are intended to demonstrate these truths–that many studies with “positive” outcomes would not be considered positive by most people in real-world situations, that negative outcomes exist, that they are not the only “science-based” approach, and reasonable people can disagree with their characterizations of maintenance as “the most effective” treatment approach.

More important than maintenance vs abstinence?

Now, it’s pretty clear to anyone who reads this blog that I believe the preferred treatment approach should be something modeled on Physician Health Programs (PHP), and that it should be available to all addicts. (I also believe that addicts should get good informed consent and have the right to choose their treatment approach.)

A sad fact is, for far too many people, their choices are inadequate medication-free treatment or inadequate medications assisted treatment (MAT). Given these choices, for a lot of people, inadequate MAT is probably less bad than inadequate medication-free treatment.

This has caused me to think about something Bill White said about another treatment argument:

Arguments over whether persons in inpatient addiction treatment should stay twenty-eight days or five days, whether outpatient treatment should be five sessions or twenty sessions, or consist of Twelve Step Facilitation or Cognitive Behavioral therapy are all arguments inside this acute care paradigm.

I wouldn’t make this argument, but one could argue that the medication-free element of PHP’s is not a critical element in their success–that it’s the elements focused on chronic disease management (or, recovery management) that are most important.

Bill White articulated a model for Recovery Management. Here are the 7 elements of his model:

There are seven elements to a comprehensive program of recovery management:

1) Client Empowerment (enfranchising persons in recovery to participate in the planning, design, delivery and evaluation of behavioral health services and to advocate for prorecovery policies and programs in the wider community),

2) Needs Assessment (identifying the needs and strengths of individuals/families experiencing severe behavioral health disorders with a particular emphasis on eliciting first-person voices of consumers and family members),

3) Recovery Resource Development (creating the physical, psychological and social space within a community in which recovery can occur; creating a full continuum of treatment and recovery support services; linking personal, professional and indigenous community resources into recovery management teams; and guiding the individual/family into relationship with a larger community of shared experience.),

4) Recovery Education and Training (enhancing the recovery-based knowledge and skills of people/families in recovery, service providers, and the larger community,

5) On-going Monitoring and Support (continuity of contact and support over time)

6) Evidenced-based Treatment and Support Services (developing services that remove barriers to recovery and enhancing “recovery capital”3 ; “trading out” less effective treatment and recovery support services for approaches that have a greater foundation of scientific support; pursuing a recovery research agenda to elucidate the structures/pathways, styles and stages of long-term recovery), and

7) Recovery Advocacy (advocating for social and institutional policies that counter stigma and discrimination and promote recovery from severe behavioral health disorders).