Dangerous Treatment and the Science of Safety

~ Jason Schwartz

We are concerned about the dangers of addiction as never before. For good reason–the opioid epidemic has become an overdose epidemic.

One undercurrent in the coverage of the issue is the implication that abstinence-based treatment contributes to overdose deaths. (There’s no question maintenance drugs reduce overdose risk and short term abstinence-based treatment of opioid addiction is irresponsible. However, there’s a lot more to the story. I’ve addressed this in several previous posts.)

A recent Addiction Professional article includes a sidebar entitled, “Dangers of drug-free treatment“.

This is pretty frustrating when the gold standard is abstinence-based and is restricted to a few elite groups.

Then, right on time, comes Kevin McCauley with his new video, Memo to Self: Protecting Sobriety with the Science of Safety.


McCauley introduces us to the Swiss Cheese Model of safety that he borrows from his background in aviation.

He uses this safety framework to propose a plan for protecting recovery. He proposes 10 protective layers. (Or, if you prefer, layers of cheese.)

His 10 layers are as follows:

  1. Treatment (residential or inpatient)
  2. A therapist, coach, and/or advocate (for regular recovery maintenance check-ups)
  3. Recovery residences
  4. Mutual support groups
  5. A relapse plan
  6. Drug testing (frequent and prolonged)
  7. Job or school (for meaning and purpose)
  8. An addiction medicine specialist
  9. Medication
  10. Hedonic rehabilitation (learning to have fun in recovery)

sw_not_aligned

Within this frame each layer provides a layer of protection and choosing to remove a layer increases the risk of relapse. This safety frame provides a way to make these risk increasing decisions more concrete and less emotionally charged. If there’s good reason to remove a particular layer, it also sets up exploration of what might be done to add another layer to replace it.

Unlike most educational videos, it’s not boring, preachy and tedious. McCauley gets us to laugh at his story and, in doing so, gets us to reflect on our own experiences with the distorted thinking of early recovery and see the importance of building protective layers to get the very precarious early months of recovery.

Further, one of the limitations of all lifestyle medicine approaches has been the dearth of knowledge about maintaining change over years and decades. This safety model provides a way of thinking through what layers are needed, not just to achieve stable recovery, but also to maintain stable recovery over years and decades.

The too-frequently and simplistically proposed solution (prescription?) for the overdose epidemic is opioid replacement medication, like buprenorphine or methadone. This model makes plain that, at best, these medications (or others, like vivitrol) compose only one layer of a safety plan. Of course, going to inpatient treatment is also only one layer.

Unfortunately, the treatment system does not deliver anything resembling this model for anyone other than doctors, pilots and possibly lawyers. This makes the video and model especially important for programs that want to improve their services as well as families and addicts that want to piece together these layers of protection on their own.

This video is a real service to treatment providers, advocates, families and addicts. It is highly recommended.

Published by Jason Schwartz

I have been an addiction professional and social worker since 1994. I started blogging in 2005 as the Clinical Director at Dawn Farm. I no longer work at Dawn Farm and am now the Director of Behavioral Medicine at a community hospital, and a lecturer at Eastern Michigan University’s School of Social Work. Views expressed here are my own. Keep in mind that the field, the contexts in which the field operates, and my views have changed over time.

7 thoughts on “Dangerous Treatment and the Science of Safety”

  1. Where do you get the impression that, inclusion of MAT (buprenorphine) would be “simplistically proposed” and (I’ll paraphrase) myopic? In our outpatient program we integrate all of your stated layers of cheese, with the inclusion of buprenorphine. It’s that tendency to simplistically define medication assisted treatment that bothers me. Our patients are treated to the entire array of layers, however, in an outpatient setting. It’s interesting that your analysis mandates “residential or inpatient”. I have, yet to find a study that indicates that inpatient provides superior outcomes to outpatient.
    There is this myth, that the problem is the substance, and if we can just replace the environment with a controlled setting, limiting access to their drug, than they will be better able to stop. Few residential programs can give any assurance that, in fact, they will be drug free but that’s not the argument. The truth, just might lie in the patient’s being able to participate in treatment (the cheese), while in their community, thus accessing family therapy (left out of the layers) and be able to de-condition the thousands of cues that induce their cravings. This is, especially, true when that day comes for discharge and the inpatient is returned to their community to face those conditioned cues, without their recovery network (which was created in the residential program’s community). How do you achieve a good continuing care component, if the patient lives 400 miles from the facility that they just left?
    Is it possible that the drug is the answer and that the patient is best able to find alternative answers, from the same folks their community recovery network? Simultaneously, de-conditioning those cue induced cravings by using their support system two or three miles from their home. And, it costs a fifth as much as sending them off to a pseudo-environment for “fixing”.
    All buprenorphine does is allow the patient to be PRESENT during the process of traveling through the layers. If they are loaded, they lack capacity and if they are in acute or post acute withdrawal, they lack capacity to concentrate and/or envision a life “beyond their wildest dreams”. That is still abstinence based, just using a medication like campral or bupe to increase the odds of a successful transition from addiction to recovery.

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    1. The majority of studies show that longer and more intensive treatment including inpatient treatment produces better outcomes, especially when long-term post treatment supports are available. Like all things, it of course depends on what you are measuring. We see that people with low social capital, or disruptive family, employment, or social problems related to their use benefit the most.

      Working in higher education, I can tell you that the professional training modules are moving to more harm reduction models in anticipation of the changing climate of healthcare. Pharmaceuticals of all varieties are part of that discussion. The newest generations of psychologists, nurses, social workers, and therapists are being taught the public health emphasis. This is even done without the discussion of abstinence as the final goal. Which is frightening to think that the treatment industry will basically outsource “stasis” or suspension of addiction to big pharma and slash money for everything else. There is little discussion

      But it is generally agreed that so the more privileged member of society (those with private insurance) in general get longer inpatient care, longer out patient care, suboxone and the like are used typically in their original context (a detox facilitating drug), they also have transitional supports such as sober living etc, and other post treatment supports.

      As we move to a more public health model, much of the longer term scenarios will go away in the name of efficiency. Taxpayers care less about quality of life outcomes and more about reduced crime and disease. Thus the treatment programs will move toward less than effective means- Shorter treatment, more medicalized, less emphasis on quality of life.

      It is important to point out that there is nothing wrong with the use of suboxone, MMT, MAT, etc. The danger is that without a coherent voice from the treatment industry, researchers, and recovery advocates, the services that are considered “treatment” will be defined along public health and harm reduction lines rather than quality of life, and enhanced stable recovery, which truly re-invents the lives of people in recovery in profound and permanent ways.

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    2. I feel like you’re rebutting arguments I did not make. This was not an anti-MAT or a pro-residential post.

      Medication is one of McCauley’s layers. I was referring to media coverage of the issue. It often suggests that the solution is as simple as prescribing more buprenorphine and methadone. I pointed out that, at best, it’s one layer–just as residential or inpatient treatment are only one layer. I even pointed out that short term abstinence-based treatment (with inpatient in mind) is irresponsible.

      You asked for evidence for residential, here are a couple:

      Opioid addicted brains recover and residential more effective than medication for young opioid addicts

      Residential Treatment Matters

      The reference to residential was based on it’s frequent use in PHPs and HIMS programs.

      You’re telling me that you use medication as one element in a comprehensive biopsychosocial program. In my experience, you’re the exception. Hats off to you.

      It’ll be interesting to watch the returns on studies of buprenorphine plus counseling. So far, they haven’t been what many people expected.

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      1. I have major concerns when politician and public officials cite that they are “doing something” about the opiate problem. Generally because the act of “doing something” only involves funding for the one layer of care (medication) and that they are only addressing one particular drug of addiction, as if they are tackling the whole of addiction in society. The European studies are relatively clear about the outcomes of long term replacement therapy creating more chronic problems, such as cognitive impairment, extreme pain sensitivity, and abuse of other drugs. So it is not a long term solution, and it addresses a very small population of people afflicted with addiction, yet it retains the majority of media and journal articles.

        Part of the big push I am working on is getting funding for recovery research which is underfunded, and very time limited. Long term, life-long recovery, earmarked by pro-social changes that completely transform the landscape of someone’s life are clearly related to a long term treatment continuum, powerful transitional supports, mutual aid, and means and access to education and vocation supports and quite simply produce life-long sustainable abstinence-based recovery. But it is not talked about, it is rarely studied, even though the mechanisms are relatively well understood by researchers. The push to “shorten” and “make efficient” what generally takes years to bring about, will effectively ensure no substantially better outcomes. Which will only propagate the stigma that addicts simply do not get any better.

        All that being said, my overall response to medication assisted therapy is simply “and then what?” – What is the next step after controlling cravings. Are we putting supports in place? Are we building community support structures, and are we developing sensible time-limited use of the drugs? Are we increasing access to life-changing recovery-cognizant systems to re-invent the whole person? There is a moral imperative to work toward both the immediate, and the long term benefit of the sufferer. So far, I feel the latter is generally left out of the public discourse.

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  2. Just a side-note. I looked up the article that you referenced re: Dangers of Drug Free Treatment and found that it chronicled the experience of a father who lost his son after “multiple rounds of treatment in drug-free programs” only to have his son die by overdose. What you left out was the real key to this issue and that is his statement: “Painfully, I have learned about evidence based treatment, and the most significant lesson was about medication-assisted treatment”. Thus, the real argument should be, why do we only tell patients and their families about one methodology of treatment. Would someone with diabetes, cancer, heart disease etc. expect that the treatment clinician would give the patient multiple options with any valuable statistics and allow them to choose. That is “patient centered treatment” and what we should all be striving towards. Perhaps, there is room for abstinence based medication assisted treatment, since that is what we have been doing for forty years. However, when it comes to buprenorphine, the biases arise and, I suspect, that the greed is born. Like A. Thomas McClellan, in his fantastic article about losing his son and never being told that there was an option to abstinence only. Mr. Flattery and his son Kevin 26 yo, should have been given the option of MAT, somewhere in that “multitude of treatment programs” that he or his insurance paid so much for. Is it possible, that there are MANY abstinence only inpatient treatment providers, who are more concerned with the fact that MAT does not require inpatient “detox” but, rather, medication stabilization, and that they do not require inpatient treatment to obtain all of the elements of quality treatment with MUCH higher outcomes? Whatever the truth, our industry is failing countless addicts every day with an unnecessarily narrow view of what recovery is. Let’s find a way to never let another Kevin die not having been told that buprenorphine is an option!!

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    1. We both want good options and good informed consent.

      I see the swiss cheese model as helpful for informed consent and shared decision making.

      It can help illustrate why time-limited doses of abstinence-based treatment are inadequate.

      However, part of good informed consent will include that, despite claims that MAT has much better outcomes, MAT research outcomes are not what many experts and media outlets suggest. (Not to mention the fact that the studies are done in such a way that anyone suggesting that have apples to apples comparative data probably doesn’t know what they are talking about or isn’t being straight with you.) The posts below are just from the past few months, and I don’t go digging for this stuff.

      Ten Years of Abstinence in Former Opiate Addicts

      Opiate-addicted Parents in Methadone Treatment: Long-term Recovery, Health and Family Relationships

      Optimism? Or, is it low expectations?

      “I would have welcomed the help, and it would have changed my life.”

      Mortality for methadone vs. buprenorphine

      Buprenorphine Outpatient Outcomes Project

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