Addiction treatment, palliative care, or both?

So . . . Monday I posted about a study of a low barrier buprenorphine program.

Toward the end of that post, I raised the tension between treatment-as-harm-reduction and treatment-as-recovery-facilitation and shared a quote from an emergency physician questioning the evidence-base for buprenorphine dispensed in emergency departments, as well as its effectiveness at facilitating “sobriety.”

I added the following:

I imagine that most people who are enthusiastic about these projects would respond that they are not looking for “sobriety.”

This is where clarity about goals for an intervention becomes especially important. If we can agree that addiction is a treatable chronic illness, it seems important to more clearly categorize interventions as treatments for the illness of addiction or as palliative care.

If we sell an intervention as treatment at the public level but treat it as palliative care at the academic level, the public, people with addiction, and people who care about them are likely to feel deceived. It also has the effect of eliding difficult conversations about resource allocation and capacity development. For example, is this $6,000,000 allocated to palliative care or addiction treatment? Because it’s not both.

I pretty quickly regretted binary framing in that last sentence but failed to add an update to the post. I just wasn’t confident that it was accurate. Sure enough, it ended up getting questioned, which is fair. (However, some reactions framed these comments as anti-palliative and anti-buprenorphine, which is incorrect.)

What is palliative care?

The US National Library of Medicine defines palliative care as:

The goal of palliative care is to help people with serious illnesses feel better. It prevents or treats symptoms and side effects of disease and treatment. Palliative care also treats emotional, social, practical, and spiritual problems that illnesses can bring up. When the person feels better in these areas, they have an improved quality of life.

Palliative care can be given at the same time as treatments meant to cure or treat the disease. Palliative care may be given when the illness is diagnosed, throughout treatment, during follow-up, and at the end of life.

For this conversation, the key elements are:

• that it prevents or treats symptoms, and
• it can be given at the same time as curative treatments

Note that they mention that it can be given at the same time as curative treatments. This establishes a distinction between curative and palliative treatments.

Palliative vs. Addiction Treatment. Is it Binary?

I wrote that without any deep consideration or conviction about this binary framing, but I gave the impression that the two approaches look something like the Venn diagram below.

Some of push back I got might give the impression that there is a high degree of overlap between the two approaches. They might view the relationship as more like the image below.

I suspect the truth might be more like the one below.

Is [enter intervention here] addiction treatment, palliative care, or both?

I am not an expert on palliative care, but I suppose the answer to this depends on the intentions and expectations of the service provider.

If the service provider’s goal and expectation are that the intervention will lead to addiction remission/recovery, then it is addiction treatment.

If the service provider’s goal and expectation are that the intervention will reduce symptoms/suffering related to addiction (but not lead to remission/recovery), then it is palliative care.

As I’ve spent a little time reading more about palliative care, I’m seeing information about concurrent palliative and curative treatment, but nothing about a single treatment being both curative and palliative.

So . . . how could I imagine an intervention being both? I could imagine, based on patient choice, delivering a treatment in a dose or intensity that is expected reduce symptoms/suffering (e.g. illicit opioid use) but is not expected to lead to remission/recovery. However, it is expected that this intervention will engage the patient into a dose/intensity that can be expected to lead to recovery/remission.

Why does it matter which kind of care it is?

In the original post (and above) I said:

If we sell an intervention as treatment at the public level but treat it as palliative care at the academic level, the public, people with addiction, and people who care about them are likely to feel deceived. It also has the effect of eliding difficult conversations about resource allocation and capacity development. For example, is this $6,000,000 allocated to palliative care or addiction treatment?

How we categorize an intervention is how we understand it, evaluate it, and communicate about it. This, in turn, will determine how others will understand it, evaluate it, and communicate about it.

If we categorize an intervention as addiction treatment, it will be (and should be) evaluated on its effectiveness at helping clients achieve recovery/remission. If it is not helping clients achieve recovery/remission, it has failed.

If the intervention is delivered with a dose and intensity that can only reasonably be expected to reduce symptoms (e.g. illicit opioid use) and it’s not accompanied by a commitment to engage the patient into a dose and intensity that can facilitate remission/recovery, it’s palliative.

It we categorize it as both, it should be evaluated on its effectiveness in engaging patients into addiction treatment of adequate dose and intensity to achieve recovery/remission.

The interventions we call treatment and their outcomes will shape how families, people with addiction, policy makers, professional helpers, employers, law enforcement, landlords, neighbors, clergy, and others think about addiction, treatment, and recovery.

Clarity is important to avoid the following traps that have harmed people with addiction:

• Selling an intervention to policy makers, helpers, the public, families and people with addiction one way, but measuring it in another way. Leading to a loss of trust and fueling stigma against recovering people.
• Moving the goalposts when outcomes are disappointing.
• Confusion about the kind of services that are or are not available to people with addiction. This confusion can nurture notions that this is an untreatable condition or that addicts don’t want recovery.
• The “soft bigotry of low expectations” that we’ve discussed here before.

This is also a time where destabilized notions of recovery with vague conceptual boundaries can create confusion that can (inadvertently) amplify these problems.

UPDATE: None of this should be interpreted as condemning low threshold programs, suggesting terminating services to people who continue to use, or suggesting that palliative services have no place. (The overdose crisis has made the need for these services clearer than ever before.)

I’d add that detox is described as palliative in TIP 19, Detoxification From Alcohol and Other Drugs because it’s not treating the disorder.

Detoxification is a set of interventions aimed at managing acute intoxication and withdrawal. Supervised detoxification may prevent potentially life-threatening complications that might appear if the patient was left untreated. At the same time, detoxification is a form of palliative care (reducing the intensity of a disorder) for those who want to become abstinent or who must observe mandatory abstinence as a result of hospitalization or legal involvement. Finally, for some patients it represents a point of first contact with the treatment system and the first step to recovery. Treatment/rehabilitation, on the other hand, involves a constellation of ongoing therapeutic services ultimately intended to promote recovery for substance abuse patients.

My intention is to call for clarity about the goals of an intervention, so we know how to understand it, evaluate it, and communicate about it.

For example, if we call detoxification treatment, and evaluate it as treatment, it will be a fail to put . Elimination of detox will seem sensible under this framing. While detox is palliative, it’s a necessary tool for many circumstances and safe engagement into other interventions.

I’d add that clarity about goals and definitions could also address the shortcomings of impatient and residential programs whose intervention is not delivered in a dose, intensity and duration that can be expected to facilitate recovery.