What should be the gold standard for addiction treatment?

This was originally published in a 2019 National Association of Social Workers’ Alcohol, Tobacco and other Drug specialty section newsletter.

The most striking thing about substance abuse treatment is the mismatch between the duration of treatment and the duration of the illness.

—Robert DuPont, MD (2018)

The opioid crisis has shined a spotlight on the U.S. addiction treatment system. Much of the coverage has focused on profiteering, the failure of states to reform their systems, the failure of programs to adopt evidence-based practices, and exploitation of patients. Many of these criticisms are well-deserved and have the potential to create opportunities to discuss how the addiction treatment system should be designed. Social workers need to involve themselves in this discussion to assure that the needs of vulnerable patients are considered and our values and priorities are represented.

“gold pills” by Sterin is licensed under CC BY-NC-ND 2.0

Several unique qualities of the opioid crisis (its lethality, its frequent iatrogenic origins, and the availability of pharmacological treatments) have raised important questions about treatment-as-usual representing a one-size-fits-all approach. It could be argued that the responses to these questions have been debates about which one-size-fits-all approach—inpatient, agonist, partial agonist, antagonist, harm reduction—should prevail. Social work’s emphasis on families, communities, social functioning and overall well-being provides a unique perspective. Where others are interested in reducing social costs, reducing medical costs, reducing symptoms, reducing crime and reducing disease transmission, we’re interested in all of those outcomes and maximizing the wellness of individuals, families and communities.

If we focus on maximizing individual wellness, a few models stand out. Professional monitoring programs for impaired pilots, lawyers and health professionals have very good outcomes and focus not just on the amelioration of symptoms, but also outcomes like returning to work. The most well-researched of these programs are physician health programs (PHPs). A large and long study of 904 physicians in 16 states reported the following 5-year outcomes(Dupont, et al., 2009):

78% of participants had no positive test for either alcohol or drugs;
Of those who experienced a relapse, only 22% had a second relapse;
Participants averaged 83 drug tests over a mean period of 54 months;
72% of participants were retained in the monitoring program;
72% of participants were still employed as physicians;
Outcomes did not differ by primary substance (alcohol, cocaine, opioids) or whether they injected drugs.

It’s important to note that this study reported on 5-year outcomes, monitored alcohol and other drug use, and reported on an important quality of life measure (return to employment). This represents a rare level of rigor.

What does this program consist of? The study proposed the following elements as the essential ingredients of the model:

Contingency management
Frequent drug testing
Active linkage to abstinence-oriented mutual aid groups
Active management of relapse with intensified treatment and monitoring
Continuing care that lasts 5 years
Focus on lifelong recovery

Most readers will wonder whether these program outcomes are relevant to the general population. Objections typically fall into three categories.

The most common objections tend to focus on the doctors as a cohort with unusually high levels of recovery capital (the quantity and quality of internal and external resources that one can bring to bear to initiate and sustain recovery from addiction) (Laudet & White, 2008). To be sure, there may be ways in which health professionals are unique in terms of recovery capital. However, they also face a unique set of barriers when initiating recovery. Another PHP study (DuPont, et al., 2009) found high rates of opioid addiction (35%), high rates of combined alcohol and drug problems (31%) and high rates of psychiatric problems (48%), and 74% were not self-referred. Further, health professionals have easy access to drugs and often develop tolerance levels that eclipse those of street addicts.

Two pieces of folk wisdom may also be relevant. First, it’s often said that doctors make the worst patients. Second, a common joke in treatment and recovery circles is, “I’ve never met anyone too simple-minded for recovery, but I’ve met plenty of people who were too smart.”

So, doctors may have unique advantages, but they also have unique barriers. If there is a difference, is there reason to believe it’s stark enough that it wouldn’t work for other addicts?

A second group of objections center around the cost of this model. While the costs of this model will not be insignificant, it could be implemented in a manner that keeps it affordable in the context of health care spending. At current public funding rates in Michigan, the following services could be provided over 5 years for under $45,000: 120 days of residential treatment, 364 drug screens, 100 outpatient group sessions, 100 outpatient individual sessions, and 5 years of recovery support and monitoring from a Recovery Support Specialist.

In the context of American healthcare spending, this does not seem to be an unsustainable burden and, in fact, is likely to be a very wise investment in pure financial terms. According to The Healthcare Bluebook, it’s similar in cost as inserting a stent–just the procedure, excluding continuing care, medications, etc. 1,000,000 stents are implanted in the US every year.

The third set of objections focus on use of coercion. Doctors often participate in these programs under threat of having their medical license suspended or revoked. Many argue that coercion is a critical element in the success of the model and that transferring the model to other patients without the element of coercion would not get us similar outcomes because coercion is such an important ingredient. This is a compelling argument. Being a doctor is more than just a high-paying job—it’s a personal identity as well as professional, and it provides a powerful source of meaning and purpose. The risk of losing their license is a very big stick, and the opportunity to return to practice is a very big carrot.

However, addiction professionals routinely encounter patients who are at risk of losing their children or their freedom. How can we be so sure that threats to their professional lives provide a unique source of motivation that cannot be created for other populations? Do we really believe that an identity like mother or father is less powerful?

This raises two questions. First, how do we build similar systems to initiate and support recovery around these other patients? Second, how can we voluntarily engage patients into these systems of care?

Fortunately, William White has developed a model of care in response to these questions. His model of Recovery Management is recovery-oriented (rather than pathology-oriented) and is based on the assumption that addiction is a chronic illness that requires management over the lifespan. Recovery Management focuses on the following elements White, W. (2005):

Models of engagement that focus on lowering thresholds, outreach and pre-treatment support services, viewing motivation as an outcome of the service relationship rather than a precondition for service initiation.
Models of assessment that are focused on the whole life of the recovering person, recovery capital, and continue over the span of the service relationship.
Service models that recognize recovery initiation and recovery maintenance are different processes requiring different forms of support, including sustained monitoring, stage appropriate recovery education and coaching, assertive linkage to local communities of recovery, and, when needed, early reintervention.
A shift in the locus of care from within the walls of the agency to the natural environment of the client.
Viewing the client as the expert on their lives, goals, and, eventually, the long-term management of their recovery rather than seeing them as the biggest barrier to their own recovery.
A shift toward service relationships as partners and allies and away from relationships that are time-limited and hierarchical.
Models of evaluation that focus on measuring the long-term effects of multiple service interventions rather than the short-term effects of single interventions.

An important benefit of this model is that it side-steps arguments over one-size-fits-all approaches by setting our focus on providing long-term recovery management.

Many states and systems of care are attempting to deploy this model, however the implementation is often incomplete, inconsistent, too focused on individual interventions, and lack comprehension of the larger vision of the model.

Social workers are the ideal addiction professionals to execute this model. Our belief in social justice requires us to challenge the disparities in care between these culturally empowered professionals and the rest of the population. Our person-in-environment perspective and strength-based approach make us the right professionals to perform assessments and deliver services within the Recovery Management model. What group of professionals is as capable of organizing communities to support recovery and reduce stigma?

As the country struggles with the consequences of the opioid crisis and temptation builds to lower the bar by narrowing our focus to the amelioration of those consequences, social workers possess the skills, values, and conceptual frameworks to construct systems of care that deliver recovery and social justice.

References

DuPont RL, McLellan AT, White WL, Merlo LJ, Gold MS. (2009), Setting the standard for recovery: Physicians’ Health Programs. J Subst Abuse Treat. 36(2):159-71. Doi: 10.1016/j.jsat.2008.01.04.

DuPont RL, McLellan AT, Carr G, Gendel M, Skipper GE. (2009), How are addicted physicians treated? A national survey of Physician Health Programs. J Subst Abuse Treat. 37(1):1-7.

DuPont R. (March, 2018) Interview with Brian Coon. Interview presented at the NC Recovery Alliance Summit, Durham, NC.

Laudet AB, White WL. (2008). Recovery capital as prospective predictor of sustained recovery, life satisfaction, and stress among former poly-substance users. Subst Use Misuse. 43:27–54.

White, W. (2005). Recovery management: What if we really believed that addiction was a chronic disorder? GLATTC Bulletin, September, 1-8. Chicago, IL: Great Lakes Addiction Technology Transfer Center.