A War on Recovery?

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STAT just ran another article in its “War on Recovery” series and continues its narrative of casting recovering people in Narcotics Anonymous and non-agonist recovery pathways as the villains.

There’s an important story undergirding this article (and the previous article attacking recovering people in NA) — that there are important gaps in social support for people on agonist medications.

A journalist could explore the failure of professionals and systems of care to develop support for the unique social and community needs of people on these medications and be curious about spaces that don’t fill those gaps. To be sure, some players should be called out for failing to meet professional obligations, while others are nonprofessional groups of community members who gather to meet their own or community needs. That requires some discernment and curiosity.

For example, the article reports that 40% of programs don’t offer medications for opioid use disorder (MOUD). To be sure, there are programs that oppose the use of agonist medications, but nonmedical programs come to mind that don’t provide medication but do coordinate care with prescribers. For example, the article reports that “In one recent government survey, 751 federally certified addiction treatment facilities reported that they do not provide methadone or buprenorphine and do not admit people taking either medication.” However, it fails to note the context that it is 751 out of 14,854 programs, or about 5%. One might question those 751 programs, but that context seems important.

My response to a previous article in the series is below. It addresses most of the salient issues raised in the article.

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STAT ran an article this week that seemed to conflate treatment, recovery, and mutual aid groups:

The recovery group Narcotics Anonymous — perhaps the country’s largest provider of addiction treatment

Lev Facher. (2024, March 5). How the U.S. is sabotaging its best tools to prevent deaths in the opioid epidemic. Retrieved March 7, 2024, from STAT website: https://www.statnews.com/2024/03/05/opioid-addiction-treatment-methadone-buprenorphine-restrictions/
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The inflammatory article is entitled “The War on Recovery” and is about barriers to access to agonist Medications for Opioid Use Disorder (MOUD), with social media posts characterizing society as making it “nearly impossible” to access these medications.

There’s little doubt that these medications are too difficult to access in some places for some people with Opioid Use Disorder (OUD).

However, the article fails to mention that:

• 63,633,687 buprenorphine prescriptions were dispensed from 2019 to 2022.
• More than 1 million people received a medication for OUD as a Medicaid benefit.
• In 2023 alone, the federal government provided $1,575,000,000 in State Opioid Response grants, much of which is spent on providing access to medications.

Of course, wherever medication is involved there’s also considerable Pharma advocacy — including helping assure that significant amounts of money from opioid settlement dollars from manufacturers are used to purchase medications from manufacturers for opioid use disorder.

And, medical associations and public health groups are aligned in their advocacy for these medications.

So… if we’re spending billions, and dispensing tens of millions, and powerful interests are aligned, who is waging this war on recovery?

Recovering addicts waging war on recovery?

The article gives the impression that Narcotics Anonymous (NA) is a key player in this war on recovery.

It also gives the impression that NA is a treatment provider — it’s not. An unfamiliar reader also might not be clear that NA is a free mutual aid program composed entirely of people recovering from drug addiction that has no lobby or financial stake.

The article described them as “actively oppos[ed]” to medication for OUD.

NA has their own definition of recovery for their fellowship, but they are not engaged in any policy advocacy and do not engage in any activity to prevent access to care with medications.

NA is a mutual aid group that was created during a period when people with addiction were abused and neglected by medical, legal, and public health systems. They self-organized to recover and help others recover.

There’s something ironic about a medical publication villainizing a group of people with opioid addiction organizing themselves and developing pathways to recovery when medical systems had failed them and often abused and abandoned them.

It’s entirely appropriate to note that NA doesn’t meet the needs of millions of OUD patients and that inappropriate referrals can be harmful.

It’s also appropriate to ask why there isn’t a thriving counterpart to NA that supports or integrates the use of medications for OUD. With buprenorphine now FDA-approved for more than 20 years, 16 million prescriptions per year, millions of Medicaid recipients (plus Medicare and private insurance recipients), and billions spent on the problem, why haven’t MOUD providers successfully cultivated the development of community-based mutual aid (rather than demanding NA change to accommodate their patients)?²

We don’t have reliable and detailed information about NA’s membership and their experiences with medications for OUD, but a 2018 membership survey reports that 14% of members completing a survey reported regular use of buprenorphine or methadone before joining NA. (This is all respondents, not just respondents with an opioid problem. 38% reported regular use of opiates and 26% reported regular use of opioids.) The average duration of abstinence among respondents was 11.4 years, meaning that, on average, they would have begun their abstinence around 2006. It’s easy to imagine that more than 14% used methadone or buprenorphine less frequently than “a regular basis” and it’s also easy to imagine that percentage would be much higher for people who joined NA more recently. My point is that this is not an agonist medication naive group and that many, if not most, of NA members with an OUD likely tried an agonist medication to treat or manage their OUD at some point in their recovery journey.

Why would a patient decline MOUD?

All of this invites questions about why a patient might 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 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, as well as 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.
• People do achieve stable, long-term recovery without MOUD, particularly within groups like NA and professional recovery programs.¹

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 extremely 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

What about retention?

We’ve got tens of millions of prescriptions filled every year. Shouldn’t we have stabilized millions of people with opioid addiction?

Well, we struggle to keep people on these medications, as demonstrated by a 2023 JAMA study on buprenorphine initiation and retention. The study looked at a database of retail pharmacy records from 2016 to 2022 that includes 92% of all retail pharmacies. (93, 713, 163 prescriptions)

What did they find? [emphasis mine]

During January 2016 through October 2022, the monthly buprenorphine initiation rate increased, then flattened. This flattening occurred prior to the COVID-19 pandemic, suggesting that factors other than the pandemic were involved. Throughout the study period, including in 2021-2022, only 1 in 5 patients who initiated buprenorphine were retained in therapy for at least 180 days, a rate similar to that found in a prior study examining data through the end of 2020.^4,5Chua K, Nguyen TD, Zhang J, Conti RM, Lagisetty P, Bohnert AS. Trends in Buprenorphine Initiation and Retention in the United States, 2016-2022. JAMA. 2023;329(16):1402–1404. doi:10.1001/jama.2023.1207

The stalled initiation rates are disappointing in the context of massive federal, state, and local efforts to increase buprenorphine treatment. The authors pointed to stigma and access issues.

I don’t doubt that stigma and barriers to access to prescribers play a role in these findings, but I imagine there are more important factors at play. After all, these were patients who received, accepted, and filled a prescription–they found a prescriber and stigma didn’t prevent them from starting treatment.

Is it possible the treatment didn’t deliver the outcomes these patients need or want? (It’s important to note that this could mean a lot of things. Some related to the medication, some not.)

For example, we know that polysubstance problems are the norm among people seeing treatment for opioid problems. If a patient presents with opioid use disorder, alcohol use disorder, stimulant use disorder, and cannabis use disorder, do they have 4 disorders? Or, do they have one disorder–addiction? If they have addiction, and we only treat opioid use, how successful is that likely to be? For someone with addiction, is “opioid recovery” an appropriate clinical endpoint?

Patients with addiction are dealing with a uniquely complex bio-psycho-social-spiritual illness. Does the treatment these patients were provided address these complex and intersecting needs? Or, did it just target one of the biological factors?

Further along these lines, these findings may point to tensions in poorly developed and poorly aligned clinical, community, and individual models for recovery and wellness. Bill White explored this in a 2012 speech:

…historically the mental health field has had a very well-defined definition of partial recovery but literally no definition, until very recently, for full recovery from severe mental illness. We now have long-term studies of the course and trajectory of schizophrenia and bipolar disorder, for example, that are really challenging that, and really beginning to signal the emergence of the concept of full recovery from some of the most severe complex psychiatric disorders.

On the addiction side, in contrast, we’ve had a very well-defined—a reified, if you will—concept of full recovery and no concept of partial recovery. In fact, it’s almost heresy to even begin to talk about a legitimized concept of partial recovery within the addictions field.

There’s a third concept within this framework that Ernie Kurtz and I ran into. We began to find scientific evidence in lots of anecdotal reports from therapists about people who got better than well. What I mean by better than well is that these are not people that we simply extracted the pathology out of their lives, but these are people who, not only went on to recover, but they went on to live incredibly rich lives, in terms of the quality of their life and service to their communities, and these are people who would later begin to talk about addiction and recovery was for them a blessing.Experiencing Recovery, 2012 Norman E. Zinberg Memorial Lecture, William L. White

This “better than well” concept fits nicely with emerging models of post-traumatic growth.

In the context of the overdose crisis, more than ever, we need legitimized models and pathways for each type of recovery to reduce harm, improve QoL, achieve stable recovery, and flourishing for the greatest number of people. And, we need to avoid pitting them against each other.

Every approach is incomplete

The truth is that there are no silver bullets. However, the scale and severity of the crisis intensify the desperation for silver bullets. Worse, the search for a silver bullet leads us astray and encourages each player to pretend to be THE solution to alcohol and drug problems.

Harm reduction is essential and an incomplete response.

Specialty treatment is essential and an incomplete response.

Medical treatment is essential and an incomplete response.

Law enforcement is essential and an incomplete response.³

Recovery communities are essential and an incomplete response.

Community action is essential and an incomplete response.

Family responses are essential and an incomplete response.

Public policy is essential and an incomplete response.

I’m sure I missed several things that are also essential and incomplete.

Does treatment need to do better? Yes. Same for harm reduction, public policy, medicine, law enforcement, and communities.

Who should take the lead? I don’t know. I’m not sure it matters if every system recognizes that it is essential and incomplete.

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1. The author pointed to some health professional recovery programs as an example of anti-MOUD bias. There is plenty of room for legitimate disagreement with the policies of these programs, on grounds of personal liberty and least restrictive care, but a journalist bringing them up ought to acknowledge their exceptional outcomes.
2. UPDATE: I had a conversation with some colleagues this morning about this. There have been efforts to establish groups like MARA in my area with little success. (There are 7 MARA meetings in Michigan, though I imagine virtual meetings have made it much more accessible to those who want to attend.) However, some colleagues reported that Drug Addicts Anonymous is growing in their region. Use of MOUD is a non-issue in DAA. DAA is a 12 step that uses AA literature, and provides a place where someone can be on bupe and share in a meeting (not widely supported in NA) that they’ve been struggling with cravings to smoke crack (not widely supported in AA). These colleagues report that the growth of DAA is, at least in part, attributable to NA and AA members starting or attending groups to provide support on MOUD who are seeking recovery. This is a good example of why groups like NA and its members should be viewed as a resource rather than scapegoated.
3. Some readers have questioned whether law enforcement should be considered an essential element. Here are a few things to consider:
   • Imagine that law enforcement was eliminated from the response to alcohol-related problems that occur at the individual, family, and community levels. Would that be a good thing?
   • Alcohol and other drug use, whether legal or criminalized, is associated with all sorts of negative externalities. Law enforcement will probably always have a role in responding to those problems. Some of those roles might be shifted to other systems or shared with other systems, but it’s hard to imagine law enforcement not playing some essential role.
   • Advocates of legalization want regulated drug markets. Who would enforce those regulations at the local, state, and federal levels? (Everything from selling to minors to regulatory corruption.)