Protection, Remission, and Recovery

Thomas McLellan and Nora Volkow, two very important figures in modern addiction and treatment science, just published a new article.

This strikes me as an important and potentially very consequential article. I’ll share a few of the things that grabbed my attention.

They describe the impetus for this article as follows:

Prescribing MOUD with a goal of protecting people who actively use drugs from overdose and infectious diseases is clearly effective. But are prescribers who take this approach settling for a suboptimal outcome? Conversely, does pursuing abstinence-based recovery unnecessarily jeopardize patient and public safety? In the absence of a consensus on realistic, achievable clinical goals for MOUD at the patient level, this controversy will persist, MOUD-penetration rates will remain low, and the public health response to the addiction crisis will remain suboptimal.

McLellan, A. T., & Volkow, N. D. (2025). Goals for Opioid Use Disorder Medications – Protection, Remission, and Recovery. The New England journal of medicine, 393(13), 1253–1255. https://doi.org/10.1056/NEJMp2505377

A few things stand out here:

• First, the recognition that systems of care and prescribers (who are centered in the current dominant models for OUD care) are settling for suboptimal outcomes when our goal is protection from overdose (which is also centered in current models),
• Second, the reference to an “absence of a consensus on realistic, achievable clinical goals for MOUD at the patient level“. A lot of the content of Recovery Review focuses on the absence of consensus on realistic, achievable goals for addiction.
  • Their focus on “the patient level” creates space for discussion about differences in public health goals and patient-level goals. A very important distinction. A massive public health level victory, like reductions in overdose, could look very different at the patient level, with extended suffering and biopsychosocial deterioration.
  • Their focus on “goals for MOUD” narrows the focus on what MOUD can (and cannot) deliver, inviting discussion of other interventions to achieve other goals.
• Note: Language in the addiction, treatment, and recovery space has gotten so confusing that, at first, I wasn’t sure what they meant by “abstinence-based recovery.” Were they referring to an expectation of cessation of illicit opioids and other drugs while on MOUD? Or, were they referring to a recovery pathway without MOUD? In the context of the rest of the article, they appear to be referring to the latter.

This might not seem like groundbreaking insight, but the overdose crisis has made public health and medicine the center of the national response to opioid use disorders. Within public health and medicine, it’s very easy to overlook the issues they highlight. That leaders of their stature are highlighting these issues is a very good thing.

---

They present the graphic above as an attempt to translate the cascade of care model to an individual level. I do have some questions about it. (Why place mutual aid in the remission row and not the recovery row? How do they distinguish remission from recovery? Their goal statement gives some hints, but it’s not entirely clear.)

However, I am REALLY happy to see them differentiate remission and recovery. We’ve frequently pointed readers to some of Bill White’s discussion of this in his monograph on recovery-oriented methadone maintenance.

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, Philadelphia Department of Behavioral Health and Mental Retardation Services and Northeast Addiction Technology Transfer Center

I’m also really happy to see them link recovery to all substance use problems, not just opioids.

While they are focused on OUD and SUD, and not confining themselves to addiction, this move points to potential integration of a couple of important insights from communities of recovery and addiction professionals.

First, it potentially integrates Narcotics Anonymous’ breakthrough idea in the 1950s–that the problem should not be conceptualized as alcohol or heroin or cocaine, but addiction.

NA’s definition of the problem as a process of “addiction” that transcended one’s drug choice and required a common recovery process may be viewed by future historians as one of the great conceptual breakthroughs in the understanding and management of severe alcohol and other drug problems. This is all the more remarkable coming at a time that substance-specific disorders were still thought to be distinct from each other, as were their treatment and recovery processes.

Budnick C, Pickard B & White W. (2011). Narcotics Anonymous: Its History and Culture

Second, at the risk of repeating the same point, it potentially integrates David Mee Lee’s practice-based knowledge. In training, he asked something like, “If a patient is addicted to cocaine, alcohol, and benzodiazepines, do they have 3 disorders?” His answer was that they had one disorder — addiction.