What makes treatment effective?

postcard---heroin-lie

I’ve been catching a lot of heat recently for posts about Suboxone and methadone. (For the sake of this post, lets refer to them as opioid replacement therapy, or ORT, for the rest of this post.

One commenter who blogs for an ORT provider challenged my arguments that we should offer everyone the same kind of treatment that we offer doctors and questioned the “it works” argument from ORT advocates. He dismissed the treatment model

Another commenter is an opiate addict who objected to a post about Hazelden’s announcement that they started providing ORT maintenance. She reported suffering greatly from cravings and relapsing after drug-free treatment at Hazelden. She’s been on Suboxone for 50 days and feels like it is a better solution for her.

Another post, that has nothing to do with me, blames abstinence-oriented treatment for the recent overdose death of an actor. (Among the other problems with the article are that she slanders abstinence-based treatment by suggesting that abuse is common. She misleads readers into thinking that ORT is not widely available when federal surveys find that ORT admissions accounted for 26% of all admissions. [Not 26% of opioid addiction admissions. 26% of all addiction treatment admissions.]

So, I thought I’d take a step back and try to address the big picture in one post.

The wrong paradigm?

Red_Drug_Pill---recoveryTo some extent, these arguments remind me of hearing Bill White comment on arguments about cognitive-behavioral therapy vs. motivational interviewing vs. 12 step facilitation. He commented that, “these are all arguments within the acute care paradigm.”

I talk often about the success of health professional recovery programs and their remarkable outcomes. What makes these programs so successful? I’d boil it down to a few factors:

  1. They are recovery-oriented. They treat patients with the expectation that they can fully recover and focus on facilitating and supporting recovery rather than just extinguishing symptoms of addiction.
  2. They have a chronic care model. They continue to provide care and support long after the acute stage of treatment (5 years). They also focus on lifestyle changes the will support recovery and look for ways to embed support for recovery in the patient’s environment.
  3. They provide adequate care. The provide multiple levels of high quality care of the appropriate intensity and duration at different stages of the patient’s recovery.

Many abstinence-oriented treatment providers have provided the first, but not the second and third. (Though one could argue that 12 step facilitation offers a long term recovery maintenance model.) They provide 10 days of inpatient care or 2 weeks of intensive outpatient and offer a passive referral to outpatient care. (Only 2% of all treatment admissions were for long term [more than 30 days] residential.) The end product looks something like a system that treats a heart attack with a few days or weeks of emergency care and then discharges the patient with no long term care plan. (Or, a weak long term care plan.) Then, we’re surprised when the patient has another cardiac event.

Many ORT providers have offered the second element, but not the first or third. The long term nature of ORT could be considered a chronic care model. However, the end product look something like palliative care for a treatable condition. It reduces opiate use (not necessarily other drug use), criminal activity and over dose. But these benefits are only realized as long as the patient is on ORT and drop-out rates are not low. And, ORT research has not been able to demonstrate the improvements in quality of life (employment, relationships, housing, life satisfaction, etc.) that we see in those health professionals who get all three elements. (Also note that opiate addicted health professionals often use VERY large doses and go undetected for long periods of time. Any neurological damage from their use does no appear to interfere with their achieving drug-free recovery in very impressive numbers.)

It’s effective!

photo credit: ntoper

photo credit: ntoper

One of the recurring arguments that I hear is that ORT is effective and there is tons of research that it’s effective. I don’t question that it’s effective at achieving some outcomes–reducing criminal activity, reducing opiate use and reducing overdose. If those are the only outcomes you care about, then you can say it’s effective without any qualifications.

Even with my bias for abstinence-oriented treatment, I can imagine circumstances where ORT might be the least bad option. (For example, if your child had been offered high quality treatment of adequate quality and duration more than once and they continue to relapse and be at high risk for fatal overdose.) A few weeks ago I offered an analogy that attempted to offer an approach to informed consent:

Maybe the choice is something like a person having incapacitating (socially, emotionally, occupationally, spiritually, etc.) and life-threatening but treatable cardiac disease. There are 2 treatments:

  1. A pill that will reduce death and symptoms, but will have marginal impact on QoL (quality of life). Relatively little is known about long term (years) compliance rates for this option, but we do know that discontinuation of the medication leads to “near universal relapse“, so getting off it is extremely difficult. The drug has some cognitive side-effects and may also have some emotional side effects. It is known to reduce risk of death, but not eliminate it.
  2. Diet and exercise can arrest all symptoms, prevent death and provide full recovery, returning the patient to a normal QoL. This is the option we use for medical professionals and they have great outcomes. Long-term compliance is the challenge and failure to comply is likely to result in relapse and may lead to death. However, we have lots of strategies and social support for making and maintaining these changes.

The catch is that you can’t do both because option 1 appears to interfere with the benefits of option 2.

Fixing treatment

Hazelden Monument2_2WEBHazelden’s adoption of ORT has provided fuel to a lot of these arguments.

Hazelden was confronted with poor outcomes for their opiate addicted patients. They saw a problem and decided to act.

One option would have been to declare that a 30 day model for opiate addiction treatment is doomed to fail and build a recovery-oriented, chronic care system that delivers high quality care of the appropriate intensity and duration.

ORT seems to be the easier response, particularly with the market and cultural currents flowing in that direction.

Bill White has argued that ORT can be compatible with a recovery orientation. I’m skeptical, but I’m watching and am willing to learn from any success they have.

However, if you can get what the doctor’s having, why would you want anything else? And, shouldn’t we want every patient to get the same kind of care the doctor would get if she were the patient? If you can’t get that, you’ve got some tough decisions to make.

I’m looking for others to implement the health professional model with others, finding ways to build upon it and make it less expensive, as we have.

 

24 Comments

Filed under Controversies, Dawn Farm, Harm Reduction, Policy, Research, Treatment

24 responses to “What makes treatment effective?

  1. Cheryl

    The preferred term these days is Medication Assisted Treatment/Recovery definitely NOT opioid replacement treatment.

    • The feds seem to use OTP. Michigan uses ORT.

      I see that methadone/suboxone advocates prefer MAR. I’m comfortable with the term if the methadone/suboxone provider is recovery-oriented. But, it’s not a term I’d use as a blanket description/label for methadone/suboxone providers.

      Thanks for the comment!

  2. Another outstanding article. Thanks, Jason, for your thoughtful analysis.

  3. Lee

    I find it highly offensive that my recovery is being defined as distinct from “abstinence” or that there are qualifications attached to whether my treatment plan- based on the use of suboxone- is “recovery oriented” or not.

    • Well, I don’t believe that “abstinence oriented”=”recovery oriented”. Maybe I should have made that more clear.

      An unfortunate truth is that most of the methadone and suboxone prescribing in this country are not in the context of a recovery-oriented program. Bill White wrestled with this as it relates to MMT and wrote an exhaustive monograph that called out the lack of recovery-orientation in MMT and called upon them to change. You can find that monograph here: http://www.williamwhitepapers.com/books_monographs/monographs/

      If you found a recovery-oriented suboxone provider, I’m happy for you.
      If you’re engaged in recovery, I don’t question your recovery and wish you nothing but the best.

      Thanks for commenting.

  4. Lucida

    I appreciate the article. Even though I’m a supporter of MAT/MAR, I can see clearly that Jason clearly devotes his life to improved chances at recovery for everyone and so I respect the care and concern behind the position. One misconception – I know several recovering physicians on Suboxone.

  5. betty risher

    Jason, Thanks again for your couragious words. There will always be those who doubt but I am glad noone gave me drugs when I left treatment many years ago. I love knowing who I really am.
    Betty

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  7. Jerry Fouchey

    I appreciate your thoughtful analysis of the issue.

  8. I am grateful Dawn Farm offers abstinence based treatment. Do you think that with Hazelden using ORT that insurance companies may deem it the gold standard thus forcing Dawn Farm to provide it? Also what impact do you think that coercion and recovery capital have on Doctors treatment outcomes? It seems to me if a person is using ORT that it is incumbent on them to make the lifestyle changes that treat the issues that ORT may not address thus making their experience recovery oriented. However many primary care docs are naive to the other issues involved in recovery besides symptom relief. Maybe providing outreach and education to primary care docs could facilitate that.

    • I’m on vacation and writing this on a tiny keyboard, so forgive the brevity.

      Insurance is a tiny portion of our revenue, so they have no sway with us. However, they do have the power to change the practices of lots of other providers.

      Regarding health care providers. Recovery capital has got to be a positive factor, though they have negative factors too–late problem identification, very large drug doses, high rates of comorbidity, teams of enablers and the conventional wisdom that docs make poor patients. Coercion is the big question to me. We know it works, so it begs a few questions. Is 100% of what PHPs do necessary to get their results? How can we get patients to do it voluntarily? How can we embed the needed support in their environment and lives to facilitate and sustain the necessary changes?

      The other big thing here is that I have no interest in forcing this on anyone, or taking options away. I just want everyone to know there’s a better way and for every one to have that option available to them.

      We’re working on the primary care thing with the Ed Series and Packard Health.

      Thanks for the comment!

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