An open paper published by the Journal of the American Medical Association this month berates residential treatment providers for not following guidance on the treatment of opioid use disorder (OUD). A study with impressive numbers (over quarter of a million admissions to residential treatment centres in the USA) seems to me to make some errors of logic which left me perplexed.
The authors say:
Several medications for OUD (MOUDs) are now considered by the medical community to be the criterion standard in initiating and sustaining long-term OUD recovery
And while this is generally right, it is not nuanced enough. Many individuals in long term abstinent recovery from opioid use disorders, in fact, would not agree with that, preferring the quality of life they have achieved through abstinence. This statement doesn’t take stock of what the highest standards of treatment focussed on abstinence can achieve.
I am a supporter of such prescribing interventions but I am also aware of their limitations and I am a supporter of choice. We medics risk being judged for ‘doctor knows best’ attitudes when we are not tuned in to what patients and their families want from treatment and what all the evidence says about how to get there.
There is undoubtedly a tension (in the UK and elsewhere I expect) between aiming for good public health outcomes in the way they are defined and helping individuals seeking abstinence from illicit and prescribed medication reach their goal. I find myself torn at times. Best practice is surely where we can hear what the patient wants, offer a range of choices, limit harm at every point and offer ongoing support. It is important not to set up medication assisted treatment against abstinence-focussed treatment and create a polarised debate. That rarely achieves much.
Choice is paramount. When people who want to achieve abstinence from prescribed and illicit drugs are initiated onto medications for opioid use disorder , are they informed how efficacious methadone and buprenorphine are at helping them get there and timescales for the journey? In Scotland the largest treatment outcome study published suggested that most people coming to addiction treatment services wanted abstinence and opiate replacement medication had the worst outcomes for this goal. Having said that, I have also re-titrated patients (with their agreement) onto opiate replacement medication when they have left treatment early and where we felt the risk of relapse was high or referred them urgently back to community teams for this purpose.
Of course we need to prioritise reducing immediate harms. Titrating someone onto opiate replacement treatment is generally the first step, but in the longer term individuals and their families often have a clear idea of what outcomes they want to achieve and some idea how they want to get there. I have had scores of patients over the years who had thought that long term methadone was their only option and who were surprised to find that others had chosen to move on and that pathways existed to help them do this while minimising risks. If most residential treatment facilities are clear in their offer – helping people to achieve abstinent recovery – it makes little sense to hold them to account on not providing methadone or buprenorphine other than for stabilisation and detox, if that’s not what people are going there for.
Of course their clients need to be informed of all the options available, but if an informed choice is made by someone to go to a facility which does not prescribe replacement opioids but which does offer other harm reduction interventions and seeks to reduce the risk of relapse robustly then surely that’s valid?
Some of the best results for those addicted to opioids going through residential treatment are for doctors. The intensity and duration of care, the follow-up and the high expectation for such patients means they achieve abstinent recovery rates in the long term that are astonishing. Sure they generally have higher recovery capital, but if these opiate-addicted doctors’ opiate-addicted patients got this standard of care what would their outcomes look like?
So in researching residential treatment, why not look at the highest standard of care in residential treatment and its outcomes and compare these with the outcomes of those seeking abstinent recovery who go onto opioid prescribing? Then you are comparing the gold standard in harm reduction with the gold standard in residential treatment while also considering what the patient wants.That could yield some very useful findings.