Some addicts are more equal

David McCartney at Wired in to recovery blogs about differences in the addiction treatment doctors receive and the treatment the rest of us get:

Doctors addicted to drugs tend to get access to higher quality treatment aimed at abstinence as a first line option, unlike their patients where aspirations are much lower. This treatment tends to be of significant intensity and duration and then there is follow up and monitoring.

Last year, I completed a study looking at what doctors in recovery felt were critical factors in their own recovery journeys. Most cited residential treatment and mutual aid as being important. Few people coming to treatment services get referred to these options.

I always wonder when I read features like this, how many more service users would find their way to enduring recovery if they received the same sort of treatment that addicted doctors do.

Peter Sheath takes it a step further and asks two questions:

My first question is, why is this so?

Opiate substitute prescribing is the main evidence based treatment for opiate dependency. Recognised internationally as being very effective in reducing the harm that drugs cause and enabling people to move away from chaotic use to stabilisation and responsible citizenship.

My second question is, are there any health care professionals out there still practising, maintained on a script?

I think that this particular issue, for me, has raised some very serious concerns. If the whole world is recognising opiate substitute prescribing as being the most effective treatment for opiate dependency, then why does this, apparently, change for health care professionals? Smacks a little of animal farm to me? “All addicts are equal, but some addicts are more equal than others.”

Peter puts his finger on 2 important matters.

First, with all of the finger wagging about MMT as the treatment approach with the strongest evidence-base, why do the most culturally empowered opiate addicts with the greatest access to the evidence base reject this evidence base with respect to their own care and the care of their peers? What does this say about the evidence and its designation as an evidence-based practice? That this evidence doesn’t offer a complete picture?

Second, what does it say that health professionals get one kind of treatment and patients get another? What drives this? Is it stigma? Is this a class issue?

6 thoughts on “Some addicts are more equal

  1. You make a very strong point in highting Peter’s observation that there is an uncomfortable reality here: that doctors appear to ignore the evidence when it comes to choosing treatment for their own addictions (at least to opiates).

    Of course, there is plenty of evidence for abstinence focussed interventions too, but it will probably never make Cochrane standards, due to complexity.

    I suppose the riposte from my profession will be around recovery capital being greater, though I’m not convinced by this, as recovery capital can be grown.

  2. The recovery capital argument is the first response I always hear when I do community education.

    To be sure, recovery capital plays a role in the success of physician treatment outcomes, but I have three problems with that argument.

    First, until we have trials giving other groups the same treatment, support, monitoring and early re-intervention, the recovery capital argument is conjecture.

    Second, to a significant extent, this brings us back to class, no? Would that mean we start tiering treatment based on recovery capital, which may, to a significant extent, be a proxy for class.

    Finally, I suspect recovery capital would predict susceptibility and treatment response for all sorts of diseases–acute and chronic. From vulnerability to influenza to treatment for diabetes and hypertension. Do we provide different treatment for those other diseases based on these kinds of factors?

  3. We have a good idea what works, but we only provide the best care to certain segments of the population, those with the highest recovery capital.
    Opiate addicts can, and do, fully recover. Expectation of abstinence and abstinence focused interventions, long term monitoring, recovery capital, adequate intensity and duration of treatment, early re-intervention and exposure to mutual aid are all factors that increase the likelihood of positive outcomes.The hope provided by the high expectations and success rates also plays a huge part.
    Lower recovery capital should indicate higher levels of care, including more of all of the above. Yet we tend to offer those with less recovery capital methadone and low expectations.
    Obviously there are severe problems with both the evidence base and with service provision. The disparities pointed out by the bloggers are extremely disturbing.It is hard to imagine an explanation that is satisfying. “uncomfortable reality” describes it well.
    Maybe we should send all opiate addicts to Med. school.

  4. On the face of it there would seem to be an irony here. Those with the greatest ability to recover are offered the intensive care approach which aims at the best possible outcome and those with the hardest challenges (the “more ill”) are offered palliation as a first line choice.

    In medicine, for other conditions, it is most often the other way round.

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