Harm Reduction and Abstinence-only Approaches to Treatment

 

 

First of all, I know the gif doesn’t have anything to do with this blog post, but I thought it was really cool, and I like langurs. It looks like he’s really enjoying his day.

 

 

 

I’m re-running a blog entry from the past, since I got some interesting comments the first time. Plus, I’m feeling lazy today, so here goes:

 

I’ve heard the harm reduction and abstinence-only debate about addiction treatment many times, not only at addiction medicine conferences, but also in my own head. In the past, I thought abstinence from all addictive drugs was the only true recovery from addiction. As I’ve aged, I’ve traveled far into the harm reduction camp, having seen people with addiction die from their disease when perhaps more could have been done to save them.

A wise mentor of mine once said try not to argue with people who aren’t actually in the room with you, so I’ve committed the debate to writing.

Following is an imaginary debate between two addiction treatment professionals. One professional believes harm reduction measures are worthwhile because they can keep people with substance use disorders alive and healthier, even if they never completely stop using drugs. The other professional feels harm reduction cheats them out of full and happy recovery, which she believes is seen with complete abstinence from all drugs.

First, they chat about needle exchange:

HR: I fully support needle exchange programs. They have been proven to reduce transmission of infectious diseases, including HIV and hepatitis. Why wouldn’t we want to help people avoid getting these potentially devastating diseases?

AO: Because giving out needles sends the wrong message. It says we are OK with people injecting drugs, and that we are willing to make it easier for them to do so. Appearing to condone drug use in any way sends the wrong message to young adults, who may be considering using drugs for the first time. Stigma towards drug users can be harmful, but perhaps stigma serves a good purpose if it discourages people from doing dangerous things like injection drug use.

HR: Studies do not show needle exchange increases the likelihood that people will start using drug intravenously. Easily available clean needles are not enough to convince a person to start injecting drugs. Besides, even if you have little compassion for the drug user, for every case of HIV we prevent with needle exchange, we save our society countless dollars in medical care. That’s just one disease. When you consider the health burden and medical costs of transmission of hepatitis C, it’s even more reasonable.

Even the ultra-conservative Mike Pence, our Vice President, changed his mind on needle exchange after an outbreak of HIV occurred in a rural community among people injecting opioids.

Besides being morally right, needle exchange makes financial sense.

AO: No, it doesn’t. It sends a message to people who inject drugs that we’ve given up on them. It says we don’t think they will ever be able to live without injecting drugs. In a way, it infantilizes them. By making drug use easier, we may cheat them out of a full and more satisfying recovery.

AO and HR move to the topic of medication-assisted treatment of opioid addiction with methadone and buprenorphine:

HR: First of all, medication-assisted treatment (MAT) is harm reduction only so far as all treatment should reduce harm. MAT is a good treatment in itself, and isn’t necessarily just a stop on the journey of recovery.

I fully support medication-assisted treatment. We have fifty years of studies that show people with opioid use disorder are less likely to die if they enroll in methadone maintenance or buprenorphine maintenance. It is one of the most heavily evidence-based treatments in all of medicine, and it is endorsed by many professional agencies, such as the Institute for Medicine, Substance Abuse and Mental Health Services Administration, the World Health Organization, and the American Society of Addiction Medicine.

We have study after study showing that people with opioid use disorder have a better quality of life when on medication-assisted treatment. We have more information about methadone because it has been use in the U.S. much longer than buprenorphine, which was approved by the Food and Drug Administration in 2002, after the Drug Addiction Treatment Act of 2000 was passed.

People with opioid use disorder who enter methadone treatment are more likely to become employed, much less likely to commit crime, and more likely to have improved mental and physical health. They receive addiction counseling as part of the process of treatment. We think buprenorphine has the same benefits, though there have been fewer studies than with methadone. We do know the risk of opioid overdose death is much lower when a person with opioid use disorder is treated with buprenorphine, too.

Because medication-assisted treatment is so effective, it should be considered a primary treatment of opioid use disorder, not only a harm reduction strategy.

AO: With MAT, people with opioid use disorder may be harmed more than if they continue in active addiction. It is no different from giving an alcoholic whiskey. Methadone is a heavy opioid that’s difficult to get off of. The opioid treatment programs that administer methadone don’t try to help these people to get off of methadone, because they make more money by keeping them in treatment. These patients are chained to methadone with liquid handcuffs forever. It’s also expensive over the long run, and patients have many restrictions put on them by state and federal governments.

HM: Methadone and buprenorphine treatments are not like giving an alcoholic whiskey, because the unique pharmacology of these medications. Both medications have a long half-life, and when patients are on a stable dose, they feel normal all day long without cravings for illicit opioids. This frees them from the unending search for drugs that occupies much of their days. Instead, they can concentrate on positive life goals. They can live normal lives while taking medication once per day that does not cause impairment or euphoria or sedation.

Also, many people with opioid use disorder still feel some withdrawal symptoms even after acute withdrawal is over. This syndrome, often called post-acute withdrawal syndrome, can cause fatigue, body aches, depression, anxiety, and insomnia. It’s unpleasant. Some people may crave opioids intensely. We think this occurs because that person’s body no longer makes the body’s own opioids, called endorphins.

Opioid use disorder is a metabolic disorder. Symptoms abate when the patient is started on appropriate replacement therapy, just like insulin with diabetes.

Methadone and buprenorphine are both very long-acting opioids. Instead of the cycle of euphoria and withdrawal seen with short-acting opioids, these medications occupy opioid receptors for more than twenty-four hours. It can be dosed once per day and at the proper dose, it eliminates craving for opioids, and eliminates the post-acute withdrawal, which is so difficult to tolerate.

And yes, methadone is difficult to taper off of, but most of the time it is in the patient’s best interests to stay on this medication, rather than risk a potentially fatal relapse to active opioid addiction. Some patients are able to taper off of it, if they can do it slowly.

Do you think of a diabetic who needs insulin as being “handcuffed” to it? What about a patient with very high cholesterol? Is she “handcuffed” to Lipitor? Do you think the doctor who continues to prescribe insulin is just trying to make money off that patient? Why is it OK for a doctor to make money from treating other chronic illnesses, but not from substance use disorders?

AO: What about the people with opioid use disorder who are doing well in abstinence-based 12-step recovery, who are healthy and happy off all opioids? Why are these people doing so well, even though their disorder was as bad as patients in opioid treatment programs? And 12-step meetings don’t cost anything.

HR: We don’t have all the answers to this question. One form of treatment, even medication-assisted treatment, won’t be right for every patient. Maybe the support that a 12-step group can provide got these people through the post-acute withdrawal. We don’t have much information about these recovering people, obviously due to the anonymous nature of that program.

If people with opioid use disorder feel OK off all opioids, that’s great. They don’t need medication. But they shouldn’t criticize the other people who clearly do benefit from medication-assisted treatment with methadone, and buprenorphine. Let’s support all options.

Besides, not all people with opioid use disorder want to go to 12-step meetings. Do treatment professionals have the right to insist everyone go to these meetings, even if patients don’t like them?

AO: Medications cheat patients out of full abstinent recovery. Methadone and buprenorphine blunt human emotions, and make it impossible to make the spiritual changes necessary for real recovery. Methadone and buprenorphine are intoxicants, and they prevent people from achieving the spiritual growth needed for full recovery. You keep these people from finding true recovery, and condemn them to a life of cloudy thinking from these medications.

HR: Various people assert patients on maintenance methadone and buprenorphine have blunted emotions and spirituality, but there’s no evidence to support that claim. How can you measure spirituality? If spirituality means becoming re-connected with friends and loved ones and being a working, productive member of society, then studies show that methadone and buprenorphine are more likely to assist patients to make those changes.

Physically, studies show patients on maintenance methadone and buprenorphine have normal reflexes, and normal judgment. They are able to think without problems, due to the tolerance that has built up to opioids. They can drive and operate machinery safely, without limits on their activities. Contrary to popular public opinion, patients on stable methadone doses are able to drive without impairment, assuming their dose is appropriate and no other substances are used that could be impairing.

People with opioid use disorder are far more likely to make significant and healthy life changes if they feel normal, as they do on medications like methadone and buprenorphine. If they chose abstinence, many times they feel a low-grade withdrawal for weeks or months, and this makes going to meetings and meeting life’s responsibilities more difficult.

Far too many people with opioid use disorder have had abstinence-only addiction treatments rammed down their throats. Most of these patients aren’t even told about the option of medication-assisted treatment, which is much more likely to keep an opioid drug user alive than other treatment modalities.

Too often, such patients cycle in and out of detoxification facilities over and over, even though we have forty years of evidence that shows relapse rates of over 90% after a several weeks’ admission to a detox facility. We’ve known this since the 1950’s, and yet we keep recommending this same treatment that has a low chance of working. And then we blame the addict if he relapses, when he was never given a treatment with a decent chance of working!

And a patient just released from a detox facility has a higher risk of dying from an opioid overdose. What other treatment in modern medicine is recommended that has such a poor response rate and an increased risk of death?

Medical professionals, the wealthy, and famous people are often treated with three to six months of inpatient residential treatment, and they have higher success rates. Physicians have about an 80% abstinence rate at five years into recovery, but besides prolonged treatment, they sign intense monitoring contracts (usually five years). They have mandated recovery meetings, random drug screens, and other supports available to them, along with loss of professional licensure if they relapse.

For most people with opioid use disorder, that kind of treatment and support isn’t available. It’s expensive, and many such patients have no insurance, or insurance that will only pay for a few weeks of treatment.

For most people, medication-assisted treatment can be a life-saving godsend. It isn’t right for every patient with opioid use disorder, but we know people are less likely to die when started in medication-assisted treatment. After patients make progress in counseling, there may come a time when it is reasonable to start a slow taper to get off either methadone or buprenorphine – or maybe not. But first we should focus on preventing deaths.

AO: Given the time, money, expense, and stigma against methadone and buprenorphine, it should be saved as a last resort treatment. If an person with opioid use disorder fails to do well after an inpatient residential treatment episode, then MAT could be considered as a second-line treatment. Let’s save such burdensome treatments for the relapse-prone patients.

HR: It seems disingenuous to claim stigma as a reason to avoid MAT when you are the one placing stigma on this treatment.

I could go on for many more pages, so let’s stop here. You get the idea.

In the past, harm reduction and abstinence were considered opposing views. I’ve heard some very smart people say this is a false dichotomy, and that in real life, these views are complementary.

I like this newer viewpoint.

Any form of treatment should reduce harm. If a patient achieves abstinence from drugs, then that’s the ultimate reduction of harm. Also, harm reduction principles can help keep drug users alive, giving them the opportunity to change drug use patterns later in life. Let’s give people more choice and more opportunities to transition out of drug use, if that’s what they desire.

Let’s do a better job of working together.

Advertisements

6 responses to this post.

  1. Posted by Scott on July 23, 2018 at 3:23 am

    I’m very much in the harm reduction camp. I truly believe we should prescribe heroin to hard to treat addicts. A consistent clean supply under medical supervision removes almost all the harms.

    I don’t understand the controversy around needle exchanges. Here in Australia you can buy syringes, waters, and antibacterial pre-injection wipes from any pharmacy no questions asked. I’m sure nobody has thought “great, I can get clean syringes, let’s start shooting drugs”. We did control the HIV epidemic rapidly though.

    Something I don’t understand about the American system (that I’d love explained) is why people get kicked off of MAT for positive drug tests. Using drugs is their disease, and exhibiting symptoms of the disease will invariably happen. They really need more help at this point, not to have it removed. Cutting them off seems like harm MAXIMISATION.

    Reply

    • Great new term: harm maximization.
      I wish I could explain it to you. When we have oversight from various agencies, inspectors exhibit consternation that we “allow” drug use among our patients. They believe that if patients are still using drugs they should be referred to a higher level of care. Many of these patients don’t want a higher level of care, so that’s a dilemma. What do I do in that situation? If I can make a case that our treatment is benefitting our patient, I’d like to keep them in treatment.

      Reply

      • Posted by Scott on July 25, 2018 at 11:42 pm

        I can see how that decision was arrived at, however it feels like it was made by a beuracrat rather than a Doctor.

        I believe if you test positive here you may lose some of your privileges (take away doses), but the policies are very clear that positive drug tests are not allowed to be the deciding factor in withdrawing treatment unless the patient is at significant risk of harm by continuing with the treatment.

        I feel sorry for my American brothers and sisters (from treatment forums). They have a relapse and are so scared of losing their treatment. Most of them want to quit but are struggling.

        It kind of feels like withdrawing someone from hypertension medication if they can’t stop eating junk food. I can’t see anyone suggesting we do that as it is obviously going to cause harm.
        It’s just sad that decisions are made regarding drug addiction treatment based on emotion and propoganda rather than good science. Even alcoholics aren’t treated that poorly.

  2. Posted by Holly Terrell on July 23, 2018 at 10:41 am

    I wholeheartedly believe in the use of both MAT and 12 step. Currently I work a very eclectic everyday program which consists of MMT, 2 different treatment plans,plus 3 different groups all rolled together. It works for me! I just celebrated 9mths. The MMT stops the compulsion and the sickness so I can work the other aspects of my recovery

    Reply

  3. “The TIP expert panel recommends offering maintenance therapy with medication, not short-term medically supervised withdrawal. The TIP expert panel also supports maintaining patients on OUD medication for years, decades, and even a lifetime if patients are benefiting.” (§3, p10, inset. SAMHSA TIP63. 2/2018)

    I think the Federal Government is mostly in the harm reduction camp except for the enforced abstinence of XR naltrexone.

    Reply

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: