Is rehab “outdated, expensive and deadly”?

This article, calling rehab “outdated, expensive and deadly” is wrong about some important things and right about some important things.

What it gets wrong

On medication assisted treatment (MAT):

It overstates the effectiveness of buprenorphine. If the medication “eliminates” and is so “effective”, you think they’d have better outcomes than this (Which is not an outlier and was spun as proof of buprenorphine’s effectiveness).
It gives false comfort about the protective effects of these medications against death by overdose.
- While the study he linked to did find death rate 50% higher for people receiving only psychosocial support vs. methadone, he failed to acknowledge a few other points of interest.
  - First, who thinks psychosocial support is an adequate intervention for opioid addiction?
  - Second, 47.5% of all overdose deaths were people currently enrolled in methadone treatment.
- I’ve blogged before that the death rate for people in MAT. It’s still very high. See here, here and here for just a few examples.
- There’s no argument that being on an opiate replacement drug reduces overdose risk, but only if they take the drug and those drugs have big patient retention problems too. (Here, here, here, here, here and here.)
It give a false impression that MAT is unavailable to most people with opioid addiction.
- It reports that 75% of opioid addiction patients are not treated with MAT, yet another government report says that 27.8% of all substance use disorder patients were treated with MAT. (Not just opioid use disorder patients, ALL substance use disorder patients.)
  - It’s also important to remember that even the higher numbers underestimate the number of people who have received MAT. Many people admitted to abstinence-based treatment have previously tried MAT.
- And, Suboxone is the number 39 drug in the US and has sales of more than $1 billion despite losing market share to generics. (Meaning that the market for the drug is growing, even if sales of the brand name version are shrinking.)

While he paints maintenance assisted treatment with a broad positive brush, he paints abstinence-based treatment with a broad negative brush. In doing so, he fails to mention that there is a model, in which residential treatment is one element, that has far superior outcomes to other approaches. This model is the gold standard and is used with addicted pilots and health professionals. (Yes, there are questions about about how differences in recovery capital and motivation might influence outcomes. But, it’s worth mentioning, isn’t it? Isn’t it reasonable to believe there’s a lot that can be learned from these programs?)

What it gets right

Treatment for opioid addiction that amounts to little more than detoxification—getting the patient to 30 days abstinent—and not following that care with robust recovery monitoring and support is dangerous.
There are a lot of phony success rates touted—in abstinence-based treatment and MAT.
Exorbitant fees for residential and inpatient treatment are common.
Charging large sums of money for inadequate care and making misleading success claims amounts to financial exploitation.
There is too little consistency and accountability in all forms of treatment—abstinence-based and MAT. There is a lot of bad care out there.
The opioid crisis is drawing attention and money to addiction treatment. As a field, the cost of failure will be huge and will set us back decades.
The length of treatment is driven by funding rather than patient need or a gold standard of care—in abstinence-based treatment and MAT.
Most programs do not provide good informed-consent—in abstinence-based treatment and MAT.

The writer doesn’t say this, but an implication of his arguments is that too many services focus on recovery initiation and too few focus on recovery maintenance.

The gold standard model includes eight, ten or fourteen elements (depending on how you count them). Offering just a few of these elements is common practice. That practice is inadequate, possibly dangerous and any marginally informed professional should know better.

What to do about it?

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.

I write frequently about the gold standard of care—the care that addicted doctors receive. They have outstanding outcomes. (I’ve even suggested that abstinence vs. MAT arguments may be a distraction from focusing on the need for long term recovery management.)

A lot of people express doubt about whether than model can be adapted to meet the needs of other people with addiction.

They say it’s too expensive.
They say doctors are different and have more recovery capital.
They say the element of coercion is essential.
They say the model is too hard to scale—especially in comparison to MAT.

All of these concerns have merit. Yet, we don’t really know because we haven’t tried.

I believe we should put effort into adapting and delivering the gold standard to all people with opioid addiction.

Where we can’t offer the gold standard to patients, we should at least tell them it exists, but it’s too expensive or there are no providers. (But, not necessarily at the expense of anything else.) Where can offer some, but not all, elements of the gold standard, we should share that information too.

Critics of abstinence-based treatment are right that there has been too little meaningful informed consent.

People with addiction should be told about the treatments that exist, and the evidence for them. When discussing the evidence for an approach, they ought to be informed about the extent to which the evidence aligns with their goals.

Then, they should be told about the treatments that are available to them. And, they ought to be told why some treatments aren’t available to them—not covered, too expensive, no provider available, policy barriers, etc.

Then, they should be free to choose the treatment they prefer. And, within reason, they should be free to change their mind.