A version of this post was originally published in November 2019.
In recent years it’s become more and more common to see advocates criticize treatment and mutual aid groups. These critics question the alleged orthodoxy and motives of treatment providers, but they do not engage in criticism of medication-assisted treatment (MAT). It appears that this would be perceived as punching down, despite the fact that it’s big business, aligned with powerful interests, and has benefited from massive federal investment.
A few weeks back, Bill White posted a new paper, From Bias to Balance: Further Reflections on Addiction Treatment Medications.
Bill’s been a forceful and effective MAT advocate for decades. He has worked hard to advocate for MAT providers and patients AND challenge providers to acknowledge and address their shortcomings. (It’s worth noting that he forcefully challenges other treatment providers in exactly the same way.)
He calls upon advocates to avoid “replacing a mindless anti-medication bias with an equally mindless pro-medication bias” and acknowledges that there are legitimate concerns behind resistance to MAT.
High treatment attrition, combined with the lack of psychosocial support during and following medication maintenance, contributes to the high addiction recurrence and mortality rates following medication cessation—death rates as high as four times that of patients remaining in treatment (Zanis & Woody, 1998; Sordo, et al., 2017). Public and professional perception of such high morbidity and mortality rates contribute to the negative perception of the long-term value of medication as a treatment for opioid addiction. The resulting bias against medication is not a product of public, professional, or patient ignorance, but results from fundamental design flaws in the pharmacotherapy of opioid addiction. If more positive attitudes toward medication support for recovery from opioid addiction are to be achieved, it will require enhanced strategies of treatment engagement and retention; amplified psychosocial supports to enhance medication adherence, global health, and social functioning (particularly for those with the most severe, complex and chronic disorders and for those choosing to taper off medication); and assertive monitoring and support following cessation of medication maintenance. (See White & Torres, 2010). It is important to disentangle one’s views about a medication from the clinical structures within which that medication is delivered.From Bias to Balance: Further Reflections on Addiction Treatment Medications
A recent SAMHSA report illustrates the retention problem Bill references.
The same report also illustrates the lack of psychosocial support at discharge.
Unfortunately the provider response to disappointing retention rates has been to strip away psycho-social-spiritual elements as though they interfere with access and retention to the real treatment—the medication.
Lowering the engagement threshold is a very worthy goal, but that should be a starting point rather than an end. It should be approached as an opportunity for the system to provide the kind of recovery-oriented amplified support that Bill describes above. He ends the paper with a call for better MAT that positions medication as one element of a comprehensive bio-psycho-social-spiritual treatment plan.
Medications are best viewed as an integral component of the recovery support menu rather than being THE menu, and their value will depend as much on the quality of the milieus in which they are delivered as any innate healing properties that they possess. If the effectiveness of medication-assisted treatment (MAT) programs is compromised by low retention rates, low rates of post-med. recovery support services, and high rates of post-medication addiction recurrence, as this review suggests, then why are we as recovery advocates not collaborating with MAT patients, their families, and MAT clinicians and program administrators to change these conditions?From Bias to Balance: Further Reflections on Addiction Treatment Medications
People seeking recovery from opioid use disorders and their families are in desperate need of science-grounded, experience-informed, and balanced information on treatment and recovery support options—information free from the taint of ideological, institutional, or financial self-interest. In an ideal world, recovery advocates would be a trustworthy source of such information.
Probably the biggest gift Bill gives to the field is the willingness to model assuming positive intent and seeking to understand the point of view of others.
For example, there is a bill pending in Pennsylvania that would require counselling accompany treatment with medication. The reaction has been swift and strong. However, it is possible to maintain the conviction that the bill is a terrible idea AND hold space for it as a well-intentioned response to serious, neglected, legitimate problems. With that in mind, I’ll leave you with this.
There is limited long-term value in replacing a mindless anti-medication bias with an equally mindless pro-medication bias. The challenge for recovery advocates is to forge a source of reliable information between the extremes of “Never” among the rabid medication haters and “Always and Forever” among the most passionate medication advocates. In our efforts to promote the legitimacy of multiple pathways of recovery—including medication-supported recovery, we need far more nuanced discussions of the potential value, the limitations, and the possible contraindications of medications across the stages of recovery.From Bias to Balance: Further Reflections on Addiction Treatment Medications