Addiction Doctors Take Aim at Abstinence-Based Drug Treatment

Feb 29, 2016

Since October, more than 120 people seeking help for addiction have been placed in residential and outpatient recovery centers through Operation Hope.

It’s a project launched by the Scarborough Police Department in response to the opioid crisis in Maine. About two-thirds of the placements have been out of state. All of them have been in abstinence-based programs that rely on the 12-step principles of Alcoholics Anonymous.

In the second of a two-part report, why some addiction medicine doctors are speaking out against the strategy.

(Click here to read the first in the series, “Operation Hope Was Designed to Help Addicts. Has It Been Successful?”)

The research, say doctors, is well established. When it comes to opioid addiction, the proven treatment is maintenance medication, either methadone or buprenorphine, commonly known as Suboxone. It’s what’s recommended by the World Health Organization, the Centers for Disease Control and the Department of Health and Human Services.

“The reality is when you add medication, you bring the relapse rate down to about 40 percent, which is still way, way, way better than counseling alone or 12-step alone or peer support,” says Dr. Meredeth Norris, an osteopathic physician in Maine who specializes in addiction using medication assisted treatment. “Am I saying that medication alone is recovery? Absolutely not. Although I work with methadone. I work with Suboxone. I’ve worked in a number of medication-assisted treatment environments, I’m always the biggest banner-waver for getting into counseling. There are many people who manage medication badly.”

Norris says data show that there are people who are able to get sober by going to abstinence-based rehab, but they’re in the minority. It usually takes them several attempts. More important, says Dr. Mark Willenbring, is that they are at high risk for relapse and for fatal overdose if they are detoxed from opioids without getting replacement medication.

“They lose their tolerance and they go out and when the inevitable recurrence happens one or two months or three months later, they will use the same amount that they used to use and they’ll overdose and die the first time they use,” he says. “It happens all the time.”

A psychiatrist, Willenbring is the former director of the Treatment and Recovery Research Division of the National Institute on Alcohol Abuse and Alcoholism at the National Institutes of Health.

Willenbring supports long-term drug replacement therapy and is now running a private clinic in Minnesota where he says he treats opioid patients with Suboxone at a cost of about $2,500 a year. Traditional, abstinence-based, inpatient rehab can cost more than $10,000 a month.

Willenbring doesn’t consider it treatment.

“The level of skill among addiction counselors nationally is abysmal,” he says. “In 13 states you don’t even need a GED to be an addiction counselor. You just need to be in 12-step recovery for two years. Across the industry there’s a 50 percent turnover rate every year. That’s why I won’t call it treatment. It’s really para-professional.”

But for those who have been successful in the 12-step program, the abstinence-based approach is the way to go. Thomas Hollmeyer says it worked for him. He’s coming up on his sixth year of sobriety. He’s also co-founder of the Amythest Recovery Center in Florida, where the company website says staff have a combined 75 years of experience.

Amythest has taken in more than a dozen patients from Operation Hope since October, for free. Hollmeyer says he’s also helped several dozen more get placed in similar programs that don’t use maintenance medication.

“We’re kind of motivating these individuals to break the cycle that they’re in as far as any Suboxone or methadone and become productive members of society,” he says. “And the best way we see the best results is to be completely abstinent.”

Steve Cotreau of the Portland Recovery Community Center helps Operation Hope coordinate placement for people desperate to find treatment. He says it’s an increasingly difficult struggle.

“All of the scholarship places are abstinence-based programs,” he says. “It’s not what we’re seeking. That’s just what is.”

Most people don’t have insurance. And while Cotreau says he and the Scarborough Police have nothing against medication-assisted treatment, they just don’t have any way to provide it. They are almost entirely dependent on free care.

“It would be great to have medication-assisted treatment step up and offer some scholarships, but that’s not the case,” he says. “People have not done that.”

In an ideal world, Cotreau says someone would walk into the police department and get a complete clinical assessment of their addiction, then be matched with the appropriate type of treatment. With Operation Hope that’s not an option, so Cotreau and other volunteers are left to take whatever they can find.

“This would not be the system that I would dream up and come up with as a solution,” he says. “This was, the building’s on fire, grab a bucket and throw some water on it.”

“Medication is more effective for more people and residential treatment, like a short-term residential treatment, all by itself is rarely effective,” says Dr. Kimberly Johnson, director of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration. She’s also a former director of the Maine Office of Substance Abuse who worked to expand access to medication assisted treatment.

But Johnson remains appreciative of the efforts of law enforcement.

“I think having law enforcement have this shift of trying to get people into treatment as opposed to incarcerating them is a great, great movement,” she says.

Now all that has to be done, Johnson says, is figure out the best way to do it.