Back in the spring, I attended the annual meeting of the National Association of Addiction Treatment Providers (NAATP) and participated in a panel discussion on the question of whether buprenorphine maintenance constitutes addiction recovery. In the context of this panel, “recovery” referred to “a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship.” The discussed question is prompted by many people in the addiction treatment community who recognize that merely not using drugs is not full recovery from the illness, and who are concerned that the medicalization of addiction treatment will actually detract from treatment outcomes.
I understand their worry, but I disagree. I think it's the wrong question. If I asked these individuals the question “Is not drinking the same as recovery?”, I bet they all would say it is not—that recovery is much bigger than not using. So why would we ask if taking a medicine is the same as recovery?
I think a better question that addresses their concerns is, “Will taking a medication prevent addiction recovery?” What I heard from some on the conference panel was that patients who are in recovery aided by medication are in a different kind of recovery from those who manage without medication. Others pointed out that medications can be abused and that doctors should not do anything that could cause harm.
Do no harm: Let's take that one first. Approximately 90% of people with the disease of addiction cannot walk into an AA meeting, sit down, get sober, get a sponsor, and work the Steps; AA acknowledges that the overwhelming majority of people who go to one meeting never make it to their fourth. For me, to do or not to do are equally active decisions. To fail to address the large group of people who die because they cannot work a recovery program without medical help is to do great harm. In fact, that constitutes much greater harm than could possibly be done to the few people who do enter treatment who receive medication they don't need.
Of course, the counter-argument could be made that some of those people on medication might leave treatment because of the medication. What most treatment programs don't look at is the very high attrition rate (in patients who are not coerced) early in treatment. More patients leave because of a lack of medication than would ever leave because of medication.
A different kind of recovery: Is one person's recovery different because he takes medication? I doubt it. Of course, not being God, I really cannot answer definitively, but I still doubt it. Is someone not in recovery because he is taking insulin? “Of course not,” the critics of medication-assisted recovery would say. “We were saying that taking a medication such as buprenorphine that works at the opiate receptor is what causes people to have a different kind of recovery.” I still don't see why. Because by stimulating the opiate receptor the patient has greater dopamine tone in his midbrain and can concentrate and enjoy his life?
The prevalent fear is that if a patient isn't suffering, he won't work the Steps. My experience is just the opposite. I have seen many people struggle to work a 12-Step program and not be able to do so until they get on medication.
But let's say that it is different to be on medication that increases dopamine tone. What about addicts in recovery who smoke? Aren't they in medication-assisted recovery? Even worse, they are not taking a dose as directed but are choosing when to use the drug. One of the NAATP conference panel members described working at an “abstinence-based program,” meaning that it did not allow medication-assisted treatment. But it did allow smoking. The irony was not lost on me.
Of course, the big bugaboo that comes into the conversation at this point is methadone (“But you don't use methadone, right?”). I don't use methadone with patients and never have. One of the reasons is because in most places I could find where methadone was used, there was no emphasis on 12-Step recovery. But what if there had been? What if, instead of the clinic setup we have in this country now, we were using methadone differently? Is methadone a problem for recovery because the drug caused a lack of recovery, or because the way we used the drug caused a lack of recovery?
Yes, there are some people who can get overly sedated on methadone, and I think there are some people who can get high from it as well. It poses a greater diversion and overdose problem for those reasons. So I personally don't see the point in using it if a safer alternative is available. But that doesn't mean there aren't people who can be in recovery on methadone. What constitutes a greater service: NA members shunning someone on methadone or NA members starting a meeting at a methadone clinic?
For me, recovery is about surrender—accepting that the illness one has is beyond one's control. That leads to understanding that one must live by certain principles that prevent the disease from flaring up. I think taking a medication as directed is as much surrender as not using a drug. Surrender is, in large part, about following directions from sober brains, not so much about what the recommendations specifically are.
My own feeling is that it's really none of my business, or anyone else's, how someone else is in recovery. I mean that both personally and as someone who treats addiction. We are treaters of an illness—not super-duper sponsors.
I think the field hurts itself by asking this kind of question. Third-party payers just hear that we are less interested in data about treatment than we are in ideological arguments. Patients hear that they have limited resources to get treatment and will not be accepted in some places. Judges and lawmakers who hear arguments about addicts having an illness see treatment providers addressing it more as a moral issue. Society in general gets confused.
So is there a role for any statement about recovery from those who treat the illness of addiction? Yes, there is. Studies show that people who engage in a recovery program after treatment do much better than those who do not. What kind of recovery? It doesn't seem to matter. Whether it's 12-Step recovery or a recovery that comes from another culture, it works if the patient works the recovery program. That's what I tell my patients.
Why is it true? Because addiction is a chronic illness and recovery programs of all kinds produce a supportive environment for actual change in the brain that can result in the amelioration of symptoms. It is the working of the program that does the trick.
For all those addiction professionals who are scared about a medication because of what they have heard from other non-physicians, I refer you to the appendix of AA's Big Book: “There is a principle that is a bar to all information … that principle is contempt before investigation.”
Howard Wetsman, MD, FASAM, is Chief Medical Officer at Townsend, a network of outpatient addiction treatment centers based in Metairie, Louisiana that combines cognitive-behavioral therapy with advanced medical treatment. His e-mail address is firstname.lastname@example.org.
For information on Dr. Wetsman's latest book designed to help patients and families, QAA (Questions and Answers on Addiction), visit http://www.addictionpro.com/gallery050608.
Addiction Professional 2008 September-October;6(5):34-35