How can peer addiction recovery supports, including access to medication-friendly mutual aid meetings, be increased for people in medication-assisted treatment (MAT)? That is a question of increasing import to people working in addiction treatment and recovery community organizations.
In this first of a two-part blog, we will briefly explore why people in MAT experience special obstacles to long-term recovery, why individuals using medication support may be in particular need of peer recovery support services, and why some individuals denied access to medication support could benefit from integrated models of medication and psychosocial support.
Participation in secular, spiritual, and religious recovery mutual aid societies and other peer-based recovery support institutions increases rates of substance use disorder remission and enhances global health and social functioning. There are FDA-approved medications that reduce addiction-related morbidity and mortality and enhance health and social functioning. Psychosocial (professional and peer) support and medication support have historically evolved as separate service organizations with their own respective philosophies about the nature of and solutions to severe alcohol and other drug problems. Fully integrating intensive psychosocial support and a full menu of pharmacotherapy choices is historically rare within the addictions field, but interest in such integration is increasing.
There are very few research studies on the experiences of MAT patients seeking participation in mainstream recovery mutual aid societies. Existing studies report high rates of past participation in 12-Step recovery groups and positive self-reports of the effects of such participation, but also note hostile attitudes toward MAT, restrictions on level of participation due to MAT status, and encouragement to progressively lower medication dosage or cease MAT. These studies also note decisions by some MAT patients to not disclose their MAT status to sponsors and fellow group members or to migrate to a fellowship less hostile to MAT (i.e., methadone and buprenorphine maintenance patients seeking support in Alcoholics Anonymous meetings rather than Narcotics Anonymous meetings). Secular and religious alternatives to 12-Step groups exist, but have been historically focused on recovery from alcohol use disorders. Mutual aid groups specifically developed for people in MAT for opioid addiction exist (e.g., Methadone Anonymous), but have been marked by instability, slow growth, and unavailability in many communities.
Similar obstacles are often encountered as MAT patients seek participation in other recovery support institutions (i.e., recovery homes), but some new recovery support institutions have exerted special efforts to extend a warm welcome to those in MAT (e.g., recovery community centers, recovery caf's, etc.). Increased access and warm welcome within mutual aid groups and other indigenous recovery support institutions could significantly elevate long-term recovery outcomes of MAT patients.
The longstanding anti-medication bias within recovery mutual aid societies has resulted in exclusion, discouragement, and second-class status of people seeking support from many of these mainstream mutual aid groups. The stigma attached to medication within these groups is rooted historically in fraudulent claims and iatrogenic effects of many medications prescribed as cures or treatments for addiction during the nineteenth and twentieth centuries. Misconceptions about the nature of medications used in MAT, inadequate dosing policies, high rates of concurrent alcohol and illicit drug use, and low quality of overall care within under-resourced opioid treatment programs has further heightened stigma attached to MAT. This anti-medication bias is slowly decreasing within both addiction treatment and recovery mutual aid settings as a result of improved quality of MAT, research on MAT effectiveness, and increased involvement of current and former MAT patients within the recovery advocacy movement.
A substantial portion of people seeking treatment for alcohol or opioid use disorders in the U.S. are not offered pharmacotherapy as a treatment service. A 2014 study by Volkow and colleagues noted that only 50% of private addiction treatment centers offered medication, with only 34% of patients in centers offering medication support actually receiving medication as part of their treatment. Similarly, less than 5% of U.S. physicians are waivered to prescribe buprenorphine for the treatment of opioid addiction. Among programs that do offer medication support, only a minority offer a full spectrum of addiction pharmacotherapies. A 2018 analysis of data from more than 12,000 addiction treatment centers in the U.S. revealed that only 41.2% of reporting centers offered at least one of three primary medications used in the treatment of opioid addiction (methadone, buprenorphine, and naltrexone), and only 2.7% of facilities offered a choice of all three medications.
Far too many people with alcohol and opioid use disorders are being repeatedly recycled through ever-briefer episodes of traditional abstinence-based treatment without achieving long-term recovery stability. (Forty-seven percent of patients admitted to addiction treatment in 2014 had one or more prior treatment admissions, and 13% had 5 or more prior treatment admissions). The above-noted anti-medication bias, the under-representation of physicians and other medical personnel within the addiction treatment workforce, and limited medication options may well contribute to such recidivism.
Many of the individuals undergoing multiple treatment episodes suffer from substance use disorders that are severe, complex, and chronic, with clinical assessments revealing non-existent or severely eroded family and social recovery supports. These are the patients who are being repeatedly recycled through treatment that does not address the complexity of their needs. It is doubtful that medication alone will alter the trajectory of their problems any more than non-medical treatments alone have, but a fully integrated combination of such approaches combined or sequenced over time across the stages of recovery might well have such potential. It is time that proposition was rigorously tested.
The majority of people admitted to medication-assisted treatment in the U.S., particularly office-based treatment of opioid addiction with prescribed buprenorphine, receive minimal, if any, peer recovery support services or assertive linkage to community-based, recovery mutual aid organizations. There are growing calls for and increased clinical experiments integrating medication support and professionally-delivered or peer-based psychosocial support, particularly in response to the recent surge in opioid addiction and its related death toll.
Substantial populations of people in MAT for alcohol or opioid dependence continue use alcohol, un-prescribed opioids, and other unprescribed drugs while in treatment. Others achieve abstinence from non-prescribed drugs, but fail to achieve larger gains in global health and social functioning. An expanded menu of psychosocial and peer recovery supports could potentially affect improvements in each of these areas.
The majority of people who commence MAT will eventually discontinue medication support, a substantial portion within the first year of medication support. Seen as a whole, the major problem with MAT is not that people remain on it too long as is often argued, but that most patients do not remain on it long enough to obtain stable recovery or sustain recovery following cessation of medication support.
Following cessation of MAT, there is increased risk of addiction recurrence, addiction-related medical disorders, arrest, and drug-related death. Providing peer support throughout the treatment process, providing all patients who are tapering with increased professional and peer supports, and conducting post-treatment monitoring and re-intervention on all MAT patients, regardless of discharge status, could potentially reduce post-treatment morbidity and mortality.
There is also an increased risk of drug-related death for people treated for opioid addiction in abstinence-based programs during the days, weeks, and months following discharge. Intensified post-treatment psychosocial support and, where indicated, combining such supports with medication support, could potentially reduce the prevalence of such deaths.
I have observed people undergoing addiction treatment for more than half a century. It is my view that many people fail in MAT due to a lack of psychosocial supports, and that many fail in traditional abstinence-based programs due to the absence of medication support. It is past time to pilot integration initiatives that rigorously evaluate the extent to which unique combinations or sequences of these interventions can improve recovery outcomes and for which clinical populations such combinations may be most needed and effective.
Treatment of chronic and severe primary health disorders involves a broad spectrum of potential interventions uniquely combined and sequenced to match the unique needs and responses of each patient. The treatment choices available to the cancer patient, for example, may include, surgical interventions, radiation, chemotherapy, pharmacotherapy, hormone therapy, immunotherapy, stem cell transplant, bone marrow transplant, gene therapy, and a minimum of five years of post-treatment monitoring with re-intervention at the earliest signs of cancer recurrence--as well as adjunctive physical therapy, dietary changes, patient and family education and peer support groups. To treat cancer offering a single fixed intervention for all patients or even the same small cluster of treatment activities would be considered professional incompetence and medical malpractice. Why then is offering a single primary intervention or limited cluster of interventions (the "program") the mainstream of clinical practice in addiction treatment? And why are the treatments used determined not by objective clinical criteria and individual needs but by the randomness of the treatment program one enters and the narrow cannon of clinical beliefs one encounters there?
It is my contention that the future of addiction treatment lies with the expansion of the treatment menu, evaluating the efficacy and effectiveness of individual treatment components, and finding the most potent combinations and sequences of services that can support personal and family recovery across the stages of long-term recovery and across diverse cultural contexts. For some, that will involve integrating medication support and a broad spectrum of psychosocial supports.
Next Week: Increasing Recovery Support for People in Medication Assisted Treatment: Suggested Strategies