I thought long and hard about whether to respond to the tone and this article [‘This is Cause for Alarm’: Abstinence-Only Opioid Treatment Is Deadlier Than None, Study Says] about a recently published study on mortality rates for people receiving treatment with Medication for Opioid Use Disorder (MOUD), abstinence-only treatment, or no treatment. The abstinence-only treatment group had a higher rate of overdose death than the MOUD treatment group and the (estimated) no treatment group.
The study’s findings should grab attention and invite scrutiny of the inadequate treatment too many patients receive.
I’ll start with the study’s findings and then address some of the zero-sum and hubristic comments quoted in the article.
The acute care paradigm fails patients
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 DuPont R. (March, 2018) Interview with Brian Coon. Interview presented at the NC Recovery Alliance Summit, Durham, NC.
A quick review of the paper finds that 78% of treatment recipients received MOUD. Of the 22% that received non-MOUD treatment, only 30% were exposed to treatment of more than 14 days.
This duration of care is doomed to fail most patients, whatever the treatment approach, and this has been known for a decades.
25 years ago, NIDA characterized 90 days as the minimum effective duration for treatment.
Recovery Management and the Acute Care Paradigm
20 years ago, Bill White was delivering presentations all over the country to encourage providers to replace their acute care models with Recovery Management — a shift from the Traditional Model (acute care) to the Recovery Model (long term disease management and recovery management).
Recovery Management sought to organize “addiction treatment and recovery support services to enhance early prerecovery engagement, recovery initiation, long-term recovery maintenance, and the quality of personal/family life in long-term recovery is described. The shift to a model of sustained recovery management includes changes in treatment practices related to the timing of service initiation, service access and engagement, assessment and service planning, service menu, service relationship, locus of service delivery, assertive linkage to indigenous recovery support resources, and the duration of posttreatment monitoring and support.” (White, 2008)
At that time, the field was consumed with competition between 12-Step Facilitation, CBT, and Motivational Enhancement Therapy for recognition as the most effective treatment model.
Bill would admonish the audience that these arguments were taking place within the acute care paradigm, and that the acute care paradigm needed to be abandoned for the treatment of the chronic illness of addiction. All therapeutic models delivered within the acute care paradigm will fail when applied to addiction.
I think about that often, particularly in these arguments about telehealth vs. “rehab”, residential vs. [fill-in-the-blank], agonists vs. antagonists, MAT vs. abstinence, harm reduction vs. abstinence.
Why would a patient decline MOUD?
The most frequently cited reason is stigma. To be sure, this explains why some people decline.
There are also other reasons people may decline agonist medications.
- Many with OUD treatment seekers have tried agonist medications before. The program I left in 2019 found that nearly 80% of patients had previously tried agonist MOUD and decided against it in this treatment episode. (This blog has many posts on retention problems with buprenorphine. Non-agonist treatments also have retention problems.)
- Many patients have experienced agonist MOUDs as part of their addiction rather than part of their recovery. (See here and here.) This experience may lead patients to seek treatment that doesn’t include agonists, but also an agonist-free environment.
- Most patients enter treatment with problems with other substances in addition to opioids and many of them are looking for recovery from addiction, not just recovery from OUD. This isn’t incompatible with MOUD but, in these cases, MOUD is a partial solution, at best.
- MOUD providers may not offer a service menu that provides pathways to patients’ most important goals.
Also, Bill White and Eric Strain, both MOUD advocates, point to another reason patients may decline agonists. The evidence base (and much of the advocacy) focuses on goals like reduced substance use and preventing overdose. Reduced use can be an important outcome and, obviously, preventing overdose is very important, but these do not represent the desired endpoints for many patients.
Bill White addresses why recovery from addiction can’t be achieved through subtraction of symptoms.
Recovery from opioid addiction is also more than remission, with remission defined as the sustained cessation or deceleration of opioid and other drug use/problems to a subclinical level—no longer meeting diagnostic criteria for opioid dependence or another substance use disorder. Remission is about the subtraction of pathology; recovery is ultimately about the achievement of global (physical, emotional, relational, spiritual) health, social functioning, and quality of life in the community.
White, W. & Torres, L. (2010). Recovery-oriented methadone maintenance. Chicago, IL: Great Lakes Addiction Technology Transfer Center.
Eric Strain questions whether the field has been ambitious enough on behalf of our patients.
This focus on opioid overdose deaths is overlooking the importance of doing more to help people than preventing a death. Not overdosing is an insufficient endpoint for treatment or for societal and medical interventions – it’s a starting point. We fool ourselves and do a disservice to patients if we allow this to be the measure that allows us to declare success. If a patient with a significant leg wound has the bleeding stopped with a compress, the medical field does not declare victory. Providers clean the wound, stitch it, arrange for physical therapy for the leg, and work to maximize the functioning of the person.
Eric Strain
He goes on to call for flourishing as the goal for patients with alcohol and other drug problems.
We should fight to ensure our patients and this field does not accept anything less than flourishing – that should be the goal we bring to our work in research and clinical practice.
Eric Strain
Where does this leave us?
I spent most of my career managing treatment programs. I believed strongly in those programs. At one of those programs, we developed a continuum of care that provided treatment and substantial, structural recovery support for more than 2 years for people with high severity, high chronicity, and high complexity cases of addiction. We devoted lots of time and energy to monitoring outcomes, patient retention, assuring quality, staff development, and integrating best practices. This program helped people whose lives had been destroyed by addiction become better than well and pursue lives full of connection, service, and personal accomplishments.
Over that time, I’ve been a vocal treatment advocate. That’s how this blog started. However, I’ve needed to be reminded over and over again that a lot of treatment isn’t worthy of that advocacy. Too many treatment programs market hope and recovery but provide care of inadequate quality, duration, and intensity. (Things like cost and credentials are often not good indicators of adequate care.) Some do it for profit, others aren’t knowledgeable or competent, and many are just following the status quo.
As the opioid crisis turned into an overdose crisis (with fentanyl as an accelerant) inadequate care became increasingly dangerous for patients, and it became increasingly important for providers to challenge inadequate and questionable care. It’s also become increasingly important for providers (and advocates) to ruthlessly interrogate their own models of care and be honest about their limitations.
I don’t believe any provider can be all things to all patients, particularly since patients come to treatment with different goals, needs, resources, preferences, etc. However, all providers can be transparent about the pros and cons of their treatment model AND the pros and cons of services/treatments they don’t offer. I’ve become convinced that this is the only path forward for ethical treatment providers — to develop rigorous models of informed consent that are repeated throughout the treatment episode and offer information and active linkage to any reasonable treatment option not offered by that provider. That informed consent is not a one-time event is critical — patients’ goals, preferences, needs, and resources change over time, particularly as they experience successes and setbacks that prompt reflection and re-evaluation of their options. Given the risks, tradeoffs, and individual factors, it’s the responsibility of the treatment provider to make sure the patient is informed and given the opportunity to choose the treatment approach that best aligns with their goals, needs, and preferences.
Leeches?
Given all of the above, some the quotes in the article about the study’s findings are really disappointing.
We’ve known for a century that abstinence doesn’t work
Robert Heimer (lead author of the study)
This ignores at least two important things:
- The past century’s history of people with opioid addiction organizing themselves and developing pathways to recovery when medical systems had failed them and often abused and abandoned them.
- The duration of care for non-MOUD patients in his study represents inadequate care, whatever the treatment method.
- It also ignores the recovery programs for some safety sensitive professions, like health professionals, pilots, and lawyers. These programs are increasingly integrating MOUD, but they have an established history of excellent outcomes with non-MOUD modes.
When we learned leeches and bleeding hurt patients, we eventually stopped the practices and sought helpful treatments.
Stephen Martin
This culture-war type framing of luddites vs. modernity disregards the limitations of all treatment and the legitimate reasons patients might choose treatment that doesn’t involve agonists.
This framing pits pathways and treatments against each other, rather than seeking to empower patients to pursue the treatment pathway of their choosing.
How to spend settlement dollars?
Some of the article’s comments extended the zero-sum framing into treatment funding — suggesting de-funding non-MOUD programs and that MOUD treatments should be prioritized for opioid settlement dollars.
While I don’t like the way these proposals are set up, they do point toward a sensible priority for settlement spending.
These comments are animated by criticisms of treatment and recovery support programs that don’t permit agonist medications. This is a frequently heard criticism of these programs.
It’s often because they know many agonist treatment patients need the services these programs provide, particularly residential treatment and housing. It would be great to see agonist treatment programs develop these services for their patients, but progress on this has been limited.
Using settlement dollars to develop residential treatment and recovery housing programs for patients on agonist medications would be a great use of settlement dollars.
It also has the potential to avoid spending opioid manufacturer settlement dollars in ways that give the dollars right back to manufacturers.
Update: One thought about the no-treatment group estimate. This compares a clinical population to a community population. These groups are likely to be apples and oranges, with clinical populations being more severe and in crisis. It’s not surprising that a clinical population receiving care much shorter than the minimum duration would have worse outcomes.
Related Posts
- 2023’s #4 Post: Zero Sum, Destructive Treatment Marketing
- A consumer’s guide to research on substance use disorders
- Nora Volkow on More Realistic And Pragmatic Addiction Treatment
- Treatment as usual isn’t cutting it (same for research as usual)
- Addiction treatment mismatch: when what’s on offer isn’t always what’s wanted
- Many [blank] treatment programs don’t offer [blank], at a deadly cost
Recovery Review 
Those are some great points, Jason. Treatment duration really has been the Achilles’ heel across most of our current approaches to SUDs. It’s probably important to note that environments around MOUD typically have much longer episodes than other modalities and that abstinence from opioids, as well as other substances, is often the goal of many of those patients. I’d also argue that folks electing to use MOUD as part of their recovery pathway are in abstinence-based recovery if they’re abstinent from the illicit use of substances.
I like the quote below, but I would also mention that residential housing and treatment are services lacking from most models of contemporary addiction treatment outside of the few who can financially access them. I’ve seen MOUD programs successfully partner with recovery homes in the same way as IOPs or other treatment approaches. This goes back to your point that not all programs can do everything. That said, I believe anyone with a severe opioid addiction should be allowed unhindered access to MOUD along with comprehensive informed consent – something also lacking from other treatment approaches outside of MOUD. There are so many folks with severe OUDs in our current environment who are challenging to retain in treatment without MOUDs to address those incredibly intensive cravings and withdrawal symptoms. The alternative often looks like white-knuckling through behavioral approaches before leading to opioid naivete and then a high likelihood of overdose in the case of a recurrence.
“It’s often because they know many agonist treatment patients need the services these programs provide, particularly residential treatment and housing. It would be great to see agonist treatment programs develop these services for their patients, but progress on this has been limited.”
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Agreed about medically supervised agonist use without other AOD use being considered abstinence.
Also agreed on that kind of informed consent applying to all treatment approaches (medical and nonmedical). I was actually thinking more of non-MOUD care.
Whatever the approach, there ought to be a review at a regular interval — How are things going? Any setbacks or succusses? Other than substance use, how QoL? Do we want to stay the course or make a change?
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I agree. The opioid treatment program I oversaw used the GDS (Global Distress Scale) with our outcomes measurement software to capture QoL metrics at each encounter (two therapy contacts per month along with intakes, tx plan revisions, etc).
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