Improve Treatment

There is a stark contrast between the lifetime nature of substance use disorders and the short-term treatments available to patients. It is not surprising that return to the use of alcohol and other drugs following treatment is a common outcome. Couple with short periods of treatment, there is often little treatment follow-up, and limited recovery support. It is hard for those with a history of substance use disorder to abstain long-term. 

Many kinds of treatment are available: inpatient, outpatient, short-term, longer-term, expensive, free of charge, insurance-paid, publicly-supported, et al. Some treatments use medications which only target specific drugs, i.e., opioids or alcohol, while some are medication-free. IBH asks what is the goal of treatment – reducing the use of a specific drug, complete abstinence from all addictive substances, or something else? There is a tendency for treatment programs of all kinds to promote the services and amenities they provide without revealing any information about program goals and success at meeting these goals, including program dropout, early termination, or relapse. This is important information to request prior to entering treatment: what is the dropout rate, is the goal to be drug-free at discharge or to be using fewer or only certain drugs, and does the program track its graduates to documents its rate of relapse?

Referral to appropriate post-treatment recovery support is essential to the long-term success of treatment.  Some of the better-known programs are the 12-step fellowships of Alcoholics Anonymous and Narcotics Anonymous, SMART Recovery, Reach for Recovery, residential support like Oxford Houses, and a variety of religious-based organizations.  Because addiction can begin at a young age, recovery high schools and recovery dorms or floors at college or universities are becoming popular. 

The Institute for Behavior and Health studies both treatment and recovery and has defined the goal of substance use disorder treatment as long-term or five-year recovery. Relapse can happen at any time, from the first hour or day of discharge, in a week or month, or after several years.  Data shows that those who reach the five year mark are less likely to relapse in the future. 

Recovery is defined as “a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship.” An estimated 23 million people in the US are in recovery from substance use disorders. Recovery means not only refraining from using the primary drug related to a substance use disorder but it means not using any alcohol or other drugs. While a diagnosis of a substance use disorder may be substance-specific, the disease of addiction is not substance-specific, nor is recovery. 

IBH recognizes that there is no one path to recovery but underscores that all substance use disorder treatment should work toward the goal of achieving long-term recovery.

How good can treatment outcomes be?

IBH conducted the first study of the nation’s state-run Physician Health Programs (PHPs), publishing a dozen academic articles on this distinctive form of care management. Participants in the PHPs complete relatively brief (30-90 days) intensive abstinence-based treatment, followed by five years of intensive monitoring for any use of alcohol or other drugs and immersion in AA, NA or other community-based recovery support programs.

Over the course of five years of intensive, random monitoring, 78% of PHP participants never had a positive test result. Notably, of those that tested positive, two thirds never had a second positive test.  Additionally, PHP participants with opioid use disorders have the same impressive outcomes as participants with alcohol and other substance use disorders.

IBH conducted a preliminary follow-up study of a cohort of physicians who, five or more years ago, successfully completed a substance use disorder monitoring contract with a PHP. Featured in Physician Health News, the summary of findings notes that “96% of physicians reported being licensed to practice currently, with none of the non-licensed physicians reporting lack of licensure as due to substance use. The vast majority (91%) of licensed physicians reported currently practicing medicine…96% of respondents reported that they consider themselves to be ‘in recovery’ now.”

IBH calls this type of abstinence-based care management of substance use disorders, which comes in many forms the New Paradigm for Long-Term Recovery.

The New Paradigm for Long-Term Recovery

It can be argued that PHP outcomes are unique because their physician participants are an irrelevant, special group. Not only is this patient population highly educated with correspondingly high incomes, but they stand to lose the source of their livelihood – their medical licenses – should they not comply with the zero-tolerance program of abstinence required by the PHPs. For that reason, IBH has turned to other programs that share many similarities with the PHP model.  These involve very different populations including pilots in commercial aviation, commercial truck drivers, and others in safety-sensitive jobs, and those within the criminal justice system. Like the PHPs these initiatives use leverage to require abstinence from drugs and alcohol. Again, because sanctions are involved, the criticism has been that such programs do not translate to larger addicted patient populations, including those with opioid use disorders, where there is no leverage similar to the leverage in the PHP, commercial aviation and criminal justice programs.  

To answer this skepticism about the generalizability of this model, IBH is working with several treatment programs serving general patient populations. The central organizing feature of these programs is post-treatment long-term monitoring with contingency management at a modest cost to achieve sustained abstinence and the significant improvements in life that are captured in the term “recovery”. This type of substance use disorder treatment mirrors the recent dramatic reinvention of heath care seen in other fields, that emphasizes lifelong chronic disease management. More information about these and other programs can be found in the IBH report, The New Paradigm for Recovery: Making Recovery – and Not Relapse – the Expected Outcome of Addiction Treatment.

Treating Opioid Use Disorders

The primary treatment policy response to the current opioid overdose epidemic has been to encourage the use of medication for opioid use disorders (MOUD) available through the office-based physician prescription of buprenorphine rather than an older form of MOUD, methadone maintenance, which is available only through methadone clinics. Naltrexone, an opioid antagonist, is a third form of MOUD, now available in daily oral form or as a once-a-month injection. It is not an opioid, as are methadone and buprenorphine, but instead it is an opioid blocker and is far less attractive to opioid-dependent patients and thus less commonly used than buprenorphine or methadone. 

IBH supports the use of MOUD but also recognizes the limitations of its use – specifically, while MOUD is often considered to be needed “for life”, the large majority of patients treated with MOUD leave treatment early and almost always against medical advice.  About half of methadone patients leave treatment in 6 to 9 months and about half of buprenorphine patients leave treatment in 3 to 6 months. The large majority patients leaving MOUD leave on substantial doses of the medication. Dropping out of treatment that is intended for a lifetime means that many are quickly returning to nonmedical drug use. Following a period of abstinence, the tolerance that was previously built up has worn off, making the time immediately after leaving MOUD treatment particularly dangerous and increasing risk of overdose.

The overall mismatch between the chronicity of the disease of addiction and relative shortness of treatment for all substance use disorders is striking. By focusing on limits of MOUD, IBH does not imply that treatments that do use medications have lower dropout rates or less drug use while patients are in treatment. The reality is that all forms of substance use disorder treatment need to be judged on their ability to achieve the goal of long-term recovery. Using medications as prescribed and NOT using other drugs non-medically is compatible with recovery.

In an interview for The Opioid Research Institute's Opioid Watch, IBH President Dr. Robert DuPont was asked, To be clear, for treatment of opioid addiction you do favor, don’t you—or do you—medication-assisted treatment over just a 12-step program without medication?  Dr. DuPont answered: 

I define this as the war in addiction treatment. The war is between the medication-assisted treatment and the “drug-free” treatment...

The drug-free programs need to offer medications as options. At the same time, medication-assisted treatments need to integrate AA and NA, and other community support, into their programs. And both programs that use and do not use medications need to be judged on their abilities to produce lasting recovery.

We need to, all together, recognize that when a patient is taking buprenorphine or methadone or naltrexone as it’s prescribed, that’s a medicine and not a drug. Use of medications as directed and no use of alcohol or other drugs of abuse needs to be defined by everyone as fully compatible with recovery.

We need to end the war between the treatment modalities for the sake of our patients and to deal with the deadly drug and overdose epidemic our nation faces today.

The IBH report A New Agenda to Turn Back the Drug Epidemic supports the 2016 Surgeon General’s Report which: 

• Defines addiction as a serious chronic illness and promotes the development of a modern continuum of public health care for it;

• Recognizes that abstinence is an achievable, high-value outcome, both for prevention and treatment;

• Acknowledges that there is a paucity of current models for systematic integration of addiction treatment and general healthcare; and,

• Encourages the identification of promising models and the promotion of innovation to achieve the goal of sustained long-term recovery, defined as no use of any alcohol or illegal drugs other than medicines that are prescribed and monitored to sustain recovery.