The gold standard and problem of coercion

i_love_evidence_based_medicine_key_chains-r33ff90ead6aa425ea368e31ca9ee70e5_x7j3z_8byvr_512I’ve written a lot on this blog about the gold standard model of treatment for addiction–health professional recovery programs.

Whenever I discuss the model, I get a lot of responses that could be placed into the category of, “Yeah, but they’re different. They’re doctors. And, besides, they’ve got a lot to lose.”

I’ve addressed the first part of that objection here.

Health professionals have more recovery capital and are more likely to recover than other addicts.

There may be ways in which health professionals are unique in terms of recovery capital. This may be true. However, they also face a unique set of barriers when initiating recovery. A study of physician recovery programs(this excludes health professionals other than physicians) found high rates of opioid addiction (35%), high rates of combined alcohol and drug problems (31%) and high rates of psychiatric problems (48%). In addition, 74% were not self-referred.

Further, health professionals confront easy access to drugs and with this ease of access to prescription drugs, they often develop tolerance levels that dwarf those of street addicts.

Two pieces of folk wisdom may also be relevant:

  • “Doctors make the worst patients.”
  • “I’ve never met anyone too dumb for recovery, but I’ve met plenty of people who were too smart.”

So…they may have unique advantages, but they also have unique barriers. If there is a difference, is there reason to believe it’s stark enough to it wouldn’t work for other addicts?

The second set of objections focus on coercion. (We’ll take away your medical license if you don’t do everything we tell you to do.)

Some of these objections argue that coercion is a critical element in the success of the model–that transferring the model to other patients without the element of coercion would not get us similar outcomes because coercion is such an important ingredient.

Other objections argue that the model is unethical because of the coercion. They point to alleged abuses by monitoring agencies. Many people with these objections seek to discredit the entire model. I’m not going to dive deep into these arguments in this post other than to make 3 statements: 1) It’s possible that monitoring agencies, assessment procedures and inclusion criteria may need to be improved in some states. 2) Where a professional’s impairment creates a public safety issue, it’s seems nearly impossible to avoid the threat of suspending/revoking their license. 3) While the model includes coercion, it also includes a lot of support and benefits–offering a path to returning/continuing to work (often quickly) and establishing support/monitoring systems in the workplace. There’s a stick, but there are also a lot of carrots.

It’s important to note that none of these objections question the actual outcomes of the model.

Is coercion necessary?

I recently had a conversation with a consultant in Washington state. They are shutting down a large facility used for involuntary treatment. (They have some sort of involuntary commitment law.) I think think she said the process was instigated by the expiration of a 99 year property lease agreement rather than some rejection of the model. Nevertheless, they are rethinking the model and wanted to hear about Dawn Farm. She was concerned about the issue of attraction to treatment. Over the course of the conversation, I told her that it is our experience that attracting people to the front door is pretty easy if you have an attractive back door. In our case, this includes:

  • safe, affordable and stable sober housing;
  • opportunities for stable employment with advancement opportunities;
  • a large, welcoming and energetic recovering community (with lots of opioid addicts in long term recovery);
  • two local collegiate recovery programs that support a path to college degrees; and
  • lots of recovery role models providing support and demonstrating that all of this is do-able.

If we can create systems that provide this kind of back door and integrate long term recovery monitoring and support, I think it could go a very long way toward overcoming the long-term-voluntary-engagement-without-coercion issue.

One interesting observation is that many of these “carrots”, like sober housing and employment opportunities, don’t seem to provide as strong a draw for people of higher socio-economic status. They have greater access to housing and employment opportunities. While material capital certainly makes achieving recovery easier in many ways, I wonder if, in this way, those with “lower recovery capital” might be easier to engage in these systems of long term recovery monitoring and support.

I’m not suggesting that we’ll have relapse rates as low as 22% over 5 years. I’m also not suggesting that it’d be easy to keep people engaged for 5 years. But, what’s possible? Huge improvements, I’d imagine. But, we don’t know, because we haven’t tried.

Imagine that we tried and engaged in continuous improvement for 10 years. How far could we go?

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