Houston, we have a problem – narrowly focused care is not the bridge to recovery we need

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Reflecting on articles on addiction and recovery that has come my way over the last week. Some encouraging, some more than a bit worrisome. In this post, I will try to weave them together in the context of long-term recovery. History shows us that framing addiction in narrow, single drug strategies sets us up time for failure. The literature seems to be reflecting we are repeating this pattern once again.

The single most important focus of substance use treatment and recovery policy in the United States should be on getting as many people as possible into long term, stable recovery. We have before us the path to expanding the number of Americans in long term recovery and the pathway that more deeply entrenches us with severe addiction in our communities.

“The problem is that policymakers and insurance companies tend to focus solutions more narrowly than we need to if we are to make any headway in expanding recovery to the millions of Americans dying from addiction. There is no doubt that we could turn this around, but to do so we need to focus on the nine tenths of the iceberg that is under the water and not just what we see above the waterline. This is what we have done over the last fifty years of drug policy in the United States and it is not working, we are still burying our loved ones dying too soon from addiction.”

Historically are systems have focused on short term, narrowly interventions with little on going engagement. While there are millions of people in recovery, we have not focused are care system on assisting people into long term recovery so millions more are not making it. We can and should do better. Which way will we go this time around?

We need to refocus on recovery and more holistic, person centered care over the long term if we are to avoid doubling down on the addiction epidemic we are in. This is an important point – we do not have an opioid epidemic; we actually have an addiction epidemic. Persons with an opioid use disorder typically also meet criteria for other, severe substance use disorders. Ignoring this will be counterproductive and lead to a more severely entrenched addiction problem and more needless loss of life.

First – some encouraging news about buprenorphine and long-term opioid abstinence with a caveat.  A recent study showed “buprenorphine participants who reported attending mutual-help groups like AA or NA at the 18-month follow-up were 2 times more likely to be abstinent compared to those who did not attend such groups, independent of the effects for agonist medications and outpatient counseling.”  This is really encouraging on several fronts. We are making headway with stigma about MAT in these fellowships. It also suggests that the use of support like 12 step fellowships (and others, as we must support all pathways) increases the likelihood of abstinence from prescription opioids.

My concern is that the study only focuses on use of prescription opioids, while as mentioned most persons with addictions are using multiple substances. This last point is an important caveat. We must look at opioid use disorder in the context of other drug addiction (including alcohol) because this is how people are using drugs.

This brings me to the second study I saw this week. It is titled Co-addiction of meth and opioids hinders treatment out of Washington State and it shows that roughly one third of the patients who were on buprenorphine were also using methamphetamine, and they tended to drop out of care. In fact, it found that methamphetamine use was associated with more than twice the risk for dropping out of treatment for opioid-use disorder.

This should be cause for deep concern and may also highlight that medication only strategies that do not include therapy and support won’t work for many people.  Choosing this narrow path can potentially lead to more severely addicted clients with more complex medical, psychiatric and psychosocial needs over the long term. We may likely see an increase in addiction related deaths as strategies that concentrate only on overdoses result in unaddressed or under-addressed needs. We both know better and deserve better.

This brings me to the third news story on a CDC report I ran across, this one from western states that noted that Methamphetamine overdose most common in chunks of US.  This should also be cause for deep concern for readers. People are dying at an alarming rate from methamphetamine. The report noted Methamphetamine was No. 4 nationwide, cited in 13% of overdose deaths. But in the four western regions, it was No. 1, at 21% to 38%.  It noted that previous CDC reports have charted meth’s increasing toll, noting that it rose from eighth to fourth in just four years.  Truth be told I could have chosen from a myriad of other reports that an increase in alcohol related deaths is one of the three factors that alcohol is a major factor leading to a lower life expectancy in the United States. Trends are clear, and they do not point to an opioid epidemic, we have an addiction problem associated among others.

Those of us who have spent are lives close to this work understand that addictive drug use is often associated with multiple substances and we should be looking at longer term interventions and support.  The problem is that policymakers and insurance companies tend to focus solutions more narrowly than we need to if we are to make any headway in expanding recovery to the millions of Americans dying from addiction. There is no doubt that we could turn this around, but to do so we need to focus on the nine tenths of the iceberg that is under the water and not just what we see above the waterline. This is what we have done over the last fifty years of drug policy in the United States and it is not working, we are still burying our loved ones dying too soon from addiction.

I say, lets focus on long term, full recovery and put our resources into restoring lives and communities. Let’s focus our polices on recovery instead of some narrow goals that fails to take the very nature of addiction into consideration. We have nothing to lose and everything to gain.

2 thoughts on “Houston, we have a problem – narrowly focused care is not the bridge to recovery we need

  1. “We must look at opioid use disorder in the context of other drug addiction (including alcohol) because this is how people are using drugs.”

    Couldn’t agree more.

  2. This post is great.

    When the bulk of AOD treatment research was focused on alcohol, we used to bemoan “drink counting” because reduced use looks great on paper and seems intuitively good, but it missed the subjective experience of the subject and their quality of life.

    This post, along with some of the others from Brian and Austin bring our attention back to the lived experience of our patients and weather their quality of life is actually improving and reaching its potential.

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