What is Drug Treatment? Science-Resistant Industry and Courts vs. Best Clinical Practices

Part 5 of Safe Supply Saves Lives: a look beyond the deadly war on drugs, a 7-part series.

Having ostensibly moved away from mass incarceration for simple use, politicians laud “addiction treatment” as the silver-bullet solution for chronic pain patients, unsheltered homelessness, and the overdose crisis alike, but they don’t typically define what methods of treatment they hope to see funded. Forced treatment is portrayed as a compassionate, even-handed, and centrist approach to substance use. Seattle Times columnist Danny Westneat, for example, recently decried Oregon’s decriminalization of possession that hands out civil fines waivable by seeking treatment.¹ Westneat calls the approach “too soft,” pointing to the over 90% of cited people who haven’t gotten treatment. Westneat also portrays Washington State’s 2021 drug law as a failure, where defendants have two strikes to be offered non-mandatory treatment before being liable for misdemeanor charges, which replaced an unconstitutional felony drug possession law.

Westneat and others like him rarely mention that the privatized industry of recovery and treatment centers is dominated by an abstinence-only model hostile to harm reduction, including FDA-approved and best practice Medication-Assisted Treatment.

Treatment Center and Clean and Sober Industry Practices

On their search result-topping webpages, most inpatient drug treatment programs will allude that while harm reduction might be the best short-term strategy for a small minority of people with a SUD, abstinence through the 1930s-era Twelve Steps² are the only true recovery. Each treatment center typically has a blog post giving the pros and cons of harm reduction versus abstinence, while showing a clear bias towards the latter. Segue Recovery of Texas, for example, points out that the “abstinence approach makes up approximately 96% of all addiction treatments,”³ as evidence experts agree it’s the best form of treatment, rather than casting a disparaging light on the treatment system’s ineffectiveness amid a growing crisis. Segue emphasizes that anything less than complete sobriety from mind-altering substances is a “slippery slope.” Treatment centers also moralize and misinform on the efficacy of FDA-approved, clinically proven SUD treatments. In one example, the Maryland Addiction Recovery Center derides Suboxone prescribing by arguing that substitution therapy is, “selling the patient short,” and that, “treating them with a “harm reduction” model rather than actually offering them comprehensive addiction treatment seems to be lazy, uninformed and shows little understanding of addiction treatment.”⁴ This is an ethical stance not backed by data.

Clean and Sober Houses are transitional housing programs targetting formerly incarcerated or unhoused people in recovery. The majority of these religiously-motivated landlords are hostile to harm reduction. According to Fred Way of the Pennsylvania Association for Recovery Residences, only seven of the 200 recovery houses he oversees accept residents on Suboxone or methadone treatment. As NPR reported, “A lot of recovery house operators are closely aligned with 12-step programs, which often count methadone or buprenorphine — technically opioids — as a violation of their abstinence-only rules,” and MAT participants are seen as “still using.”⁵

A frequent line from Twelve Step organizations is that people in recovery have an “addictive personality,” and using any other mind-altering substance, except caffeine and nicotine, puts the participant at high risk of “substitution.” Alcohol Use Disorder patients are told they can never responsibly use cannabis, and people participating in MAT programs are relying on a “crutch” that must be taken away. The theories of substitution and “addictive personalities” are contradicted by available evidence. In a study of more than 34,000 participants over a 3-year period, people in remission from a SUD were less than half as likely to develop a new SUD as people who did not have a history of SUD. The authors conclude that, “Achieving remission from 1 SUD and abstaining from substance use may have the added clinical benefit of helping to prevent the onset of new SUDs.”⁶

In this article, Behavioral Health Centers of South Florida states that illicit drug use is inherently deadly and never acceptable, so the very concept of harm reduction shouldn’t apply the way it can for alcohol.⁷ BHC denies that measurable reductions in alcohol consumption are a desired outcome, calling it “arbitrary,” and focuses on concern for condoning use:

You cannot tell a person abusing heroin that it’s okay to shoot up once in a while, or a person addicted to cocaine that doing a couple of lines here and there is fine. Even single instances of drug abuse can lead to overdose and death, which makes harm reduction an ill-advised strategy when dealing with illicit drugs.

Lastly, how does one measure success or failure in harm reduction? Does going from six beers per day to five qualify as successful? The arbitrary nature by which harm reduction strategies define success makes it easy for individuals to claim they’ve made progress, especially when compared to abstinence treatment, which requires complete cessation of substance abuse.

When BHC goes on to admit that programs such as methadone and needle exchanges reduce societal damage, the framing suggests that reduced consequences to substance use is not helpful for people struggling with addiction. When addiction is a disease that can only be morally treated by “turning our lives over to the care of God,” at “rock bottom,” reducing the threat of sudden death can be seen as counterproductive.

Medication-Assisted Treatment

In absence of a genuine safe supply like we have for alcohol, two key Medication-Assisted Treatments (MATs) are currently available in the United States for opioid use disorder and are proven effective. In a study between 2015 and 2017 of over 40,000 individuals with an opioid use disorder, Wakeman et al (2020) compared the outcomes of patients receiving Suboxone, methadone, inpatient detoxification treatment, and no treatment.⁸ Suboxone and methadone participants had a 59% reduction in the rate of overdose at the 12-month mark and a 26% reduction in serious opioid-related acute care incidents. In contrast, participants in inpatient detoxification and intensive behavioral health treatments had the same rate of overdose and acute care as the participants who had not engaged in any treatment at all. In aggregate, abstinence-based treatment has no effect on reducing the risk of drug overdose, while MATs make a measurable improvement.

Suboxone

Suboxone is a brand name for the combination of buprenorphine with naloxone. On its own, buprenorphine, a partial opioid agonist, has similar mild effects to other opioids at low doses but has a ceiling effect that prevents higher doses from increasing the high. Buprenorphine can reduce the withdrawal effects of discontinuing other opioids. Contradicting any opioid effect is naloxone, which shuts off opioid receptors, putting the patient in withdrawal. When working as intended, cravings for other opioids are reduced, and when they are used, naloxone present in a patient’s system provides some protection.

It’s a very appealing concept for clinicians sympathetic to the harm reduction perspective: we’re not going to force you to stop using drugs, but we think this prescription might reduce your desire to use while reducing your risk of death regardless of what you do. It doesn’t work for some patients, however, who report constant nausea when the balance of two meds fighting it out simultaneously reducing and causing withdrawal symptoms is not working in their favor. Patients who have discontinued Suboxone participation report that Suboxone eliminated the sense of euphoria they got from opioids,¹⁰ something they’re not always ready, wanting, or able to sustain. Suboxone is a relatively low-barrier prescription to get, not requiring daily program participation or severe oversight of clinics.

Despite the infinitesimal potential for abuse or overdose, the DEA is currently working to reimplement prescribing barriers that were reduced as part of the pandemic response. DEA lawyer Larry Cote equated the data point that they’ve seen “a lot more prescribing” of Suboxone since the pandemic started with the harmful conjecture that “improper prescribing” is happening.¹¹ This is gibberish to anyone who knows the first thing about Suboxone.

Methadone

Methadone is also a mild opioid and can eliminate cravings and withdrawal symptoms, while not functionally getting participants “high” at the monitored dosages. Methadone, lacking the ceiling and antagonist of Suboxone, is tightly controlled. In most cases, patients must attend early morning appointments daily to take their dose in person for months before they’re trusted enough to take even a few days worth of medication home. Patients are also regularly drug tested, and can have their dose cut or terminated from the program for using illicit substances or missing methadone doses.

These programs are often rare, full, or limited in availability in even large cities. Evergreen Treatment Services, Seattle’s methadone provider with walk-in intake, only does so from 7:30am to 8:30am Monday to Thursday. When a patient dependent on opioids is hospitalized, they may be provided inpatient fentanyl or methadone maintenance, and the ER social workers would ideally like to maintain a continuity of care to an outpatient program. However, if they’re getting discharged on a Thursday, they’ll have to wait at least 4 days, and in that time will need to use illicit substances to prevent severe withdrawal symptoms.

The US government’s reasoning behind these layers of regulation is to prevent the “diversion” of prescription methadone onto the street market.¹³ Crackdown Podcast host Garth Mullins, a longtime methadone maintenance participant, points out how counterproductive this is: before he entered methadone treatment, he tested the waters by trying it out from a “diverted” supply.¹⁴ That use was undoubtedly safer than the heroin he would have otherwise used, and its availability got him to consider and ultimately do the work to enter MAT despite its barriers. Reducing the supply of legitimate medication to be diverted is exactly why the overdose crisis got so bad.

Amphetamine MAT

No such MATs currently exist for methamphetamine users in the US, despite a body of evidence that many methamphetamine users would benefit from legitimate ADHD or ADD treatment. Methamphetamine users are estimated to be 2-6 times more likely to have ADHD than the general population, with one study putting the figure at 21% of meth users.¹⁵ Rather than a Substance Use Disorder, this should be seen as self-medicating due to a lack of access to legitimate providers. A 19-year-old with ADHD who self-medicates with methamphetamine reported in a case study that “methamphetamine has a calming and stabilizing effect on his mental state,” similar to the clinical use of Adderall or Ritalin.¹⁶ Self-medicating ADHD currently puts users at risk of opioid overdose from supply contamination, as well the “overamping” on methamphetamine itself. With a finger on the pulse of maximizing harm, the DEA is currently cracking down on startup websites that offer low-barrier ADHD treatment appointments that were initially enabled by loosened pandemic telehealth regulations.¹⁷

Methadone and Suboxone are limited and insufficient to replace the deadly street supply, but their existence is a proven model that medication maintenance is more effective than abstinence at actually preventing death. Srivastava et al (2017) concluded in the Canadian Family Physician Journal:

Both methadone and buprenorphine-naloxone are substantially more effective than abstinence-based treatment. Methadone has higher treatment retention rates than buprenorphine-naloxone does, while buprenorphine-naloxone has a lower risk of overdose.¹⁸

Civil Commitment for Involuntary Treatment

The US National Institute of Drug Abuse endorsed forced treatment as a principle until recently, noting in their 2014 Principles of Drug Addiction Treatment guidelines that, “Treatment does not need to be voluntary to be effective. Sanctions or enticements from family, employment settings, and/or the criminal justice system can significantly increase treatment entry, retention rates, and the ultimate success of drug treatment interventions.”¹⁹ NIDA did not cite any particular research for this assertion that continues to be reiterated by treatment centers. Since then, however, NIDA Director Dr. Nora Volkow has reckoned, “The data does not show that it’s beneficial to put someone in jail or prison or force them against their will to go to treatment. […] There are absolutely instances where people may have had a positive outcome, but it’s the minority.”²⁰ The very notion of involuntary treatment violates the basis of informed consent that any care plan should be built on. “In a therapeutic relationship, patients have autonomy and must provide informed consent prior to commencing any treatment or procedure. In a coercive setting such as involuntary civil commitment, patients have no autonomy to affirmatively choose treatment, ” wrote adjunct professor Michael Sinha at Loyola University Beazley Institute for Health Law and Policy to journalist Jordan Michael Smith.²¹

Forced detox, treatment, or incarceration is not only ineffective, it exposes patients to a heightened risk of death. When returning home with a lower tolerance after detoxing, patients are at a high risk of overdosing from the level of consumption they were previously accustomed to. In the four weeks after discharge from non-MAT treatment programs, Ravndala and Amundsen observed a dramatic excess mortality rate ratio of 15.7 among 276 heroin users in Norway²².

Patient receives “treatment” at Massachusetts Alcohol and Substance Abuse Center in Plymouth (Photo Credit: *Robin Lubbock/WBUR*)

Massachusetts is the leading state for involuntarily committing people for addiction treatment, and the results are both cruel and ineffective. Under civil commitment, any community member can report that someone’s Substance Use Disorder alone poses a grave threat to themselves or others, resulting in an order for involuntary treatment. The state’s own report notes the correlation that “those who received involuntary treatment were 2.2 times more likely to die of opioid-related overdoses […] compared to those with a history of voluntary treatment and no history of involuntary treatment.”²³ Stonybrook, a civil commitment addiction treatment center in Hampden County, is located in a medium-security prison. Despite flaunting language of being “trauma-informed,” as of 2019 patients were handcuffed for transport, referred to as “offenders” by guards, and placed in a prison cell, seatless toilet and all. Involuntary treatment can also be literal jail. In Sarasota County, Florida, 1,000 ‘patients’ committed for substance use disorder each year spend time in jail while awaiting one of twenty treatment beds.²⁴

Carceral Treatment System

Incarcerated Treatment Access

It’s important that incarcerated people have access to evidence-based SUD treatment options. Medication-Assisted Treatment has gained traction in prisons and jails during the pandemic due to the lower infrastructure demands allowed by telehealth prescribing, with doses received growing by 471% from 2018 to October 2020.²⁵ However, the availability and legality of MAT under incarceration still varies widely across US states and counties, with many systems having only very small pilot programs, only serving inmates who were in MAT prior to incarceration, or requiring rapid tapering.²⁶ The court system has a history of deep entanglement with the Twelve-Step movement in its “tough love” approach to possession charges. Twelve Step-based programs remain the only option for incarcerated people and drug court subjects in many jurisdictions. This is despite a severe need for MAT: one-third of the incarcerated population has an opioid use disorder, and inmates are threatened by both forced detox and illicit drug overdose.

Drug Courts

Drug courts allow the diversion of drug-related crime defendants from charges toward court-ordered addiction treatment. While this may seem like a step away from criminalization and towards treating Substance Use Disorder as a medical concern, relapse or failure to comply with drug court orders can result in much harsher punishments than the original sentence would have been. Brought to light in a 2011 episode of This American Life, Lindsey Dills of Georgia, was caught at the age of 17 having forged $100 of her parent’s checks that they suspected she would’ve used to buy cannabis.²⁷ In the traditional court system, let alone juvenile court, this crime would garner a plea deal for a few months of probation. Her parents, however, turned her into drug court, which seized her autonomy from 2005 to 2012, including 14 months in jail and time in solitary confinement. During solitary confinement, she was denied access to her anti-depressant prescription and attempted suicide. Judge Amanda Williams gave cruel and excessive punishments to Dills for using alcohol and being suspected of using cannabis. Williams’ sentences were out of the ordinary for drug courts, and her career ended in disgrace, but use of short jail terms in response to relapse is standard practice.

Brandi Byrd, another drug court defendant of Judge Williams featured in This American Life, had been searched by police with two pain relief pills from her mother’s prescription that her mother had provided for a minor gynecological operation. Ordered to participate in an addiction treatment program, Byrd failed due to her unwillingness to lie and ‘accept’ she had an addiction. As a result of being “treatment resistant,” Judge Williams sentence her to 20 months in prison. If she had not been originally sent to drug court, she would have likely been given a plea deal with a short probation term.

Treatment isn’t for all

Drug treatment expansion as the catchall solution to rising overdoses ignores that overdose and addiction are not inherently the same. Medication-Assisted Treatment is the best available care plan for many people with a SUD, and abstinence-based programs are appropriate for others. However, neither are relevant for people who do not have a Substance Use Disorder yet are still facing severe risk during this crisis. This includes chronic pain patients at risk of overdose because they can no longer access their medication, as well as people recreationally experimenting in ways that were never this risky in the past. Teenage drug overdose deaths doubling in a time period when use was stagnant indicates this. A party goer believing it’s real ‘Oxy’ or ‘bars of Xanny’ going around may be more likely to die of an overdose than someone who smokes ‘blues’ on a daily basis knowing they’re fentanyl. People overdose on illicit drugs because they have no way of knowing the dosage or contents of the substance, not because of necessarily having a Substance Use Disorder.

Keep reading in Heroin-Assisted Treatment, Harm Reduction, and the History of Safe Supply

References

1
Westneat, Danny. “Between Prison and Pamphlets: WA Looks for an Answer to the Drug Crisis.” The Seattle Times, December 3, 2022. https://www.seattletimes.com/seattle-news/politics/between-prison-and-pamphlets-wa-looks-for-an-answer-to-the-drug-crisis/.
2
Twelve Steps 1. We admitted we were powerless over our addiction — that our lives had become unmanageable. 2. Came to believe that a Power greater than ourselves could restore us to sanity. 3. Made a decision to turn our will and our lives over to the care of God as we understood Him. 4. Made a searching and fearless moral inventory of ourselves. 5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. 6. Were entirely ready to have God remove all these defects of character. 7. Humbly asked Him to remove our shortcomings. <br>8. Made a list of all persons we had harmed, and became willing to make amends to them all. 9. Made direct amends to such people wherever possible, except when to do so would injure them or others. 10. Continued to take personal inventory and when we were wrong promptly admitted it. 11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out. 12. Having had a spiritual awakening as the result of these Steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.
3
Segue Recovery. “Why Abstinence Is Necessary for Recovery | Lasting Sobriety.” Segue Recovery – Sober Living Austin, TX, June 30, 2019. https://www.brcrecovery.com/segue-recovery/abstinence/.
4
Snitzer, Zachary. “The Dangers of Long Term Suboxone Use.” Maryland Addiction Recovery Center (blog), March 23, 2020. https://www.marylandaddictionrecovery.com/the-dangers-of-long-term-suboxone-use/.
5
Feldman, Nina. “Many ‘Recovery Houses’ Won’t Let Residents Use Medicine To Quit Opioids.” NPR, September 12, 2018. https://www.npr.org/sections/health-shots/2018/09/12/644685850/many-recovery-houses-wont-let-residents-use-medicine-to-quit-opioids.
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7
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8
Wakeman, Sarah E., Marc R. Larochelle, Omid Ameli, Christine E. Chaisson, Jeffrey Thomas McPheeters, William H. Crown, Francisca Azocar, and Darshak M. Sanghavi. “Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder.” JAMA Network Open 3, no. 2 (February 5, 2020): e1920622. https://doi.org/10.1001/jamanetworkopen.2019.20622.
9
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10
Crackdown Podcast. “Editorial Statement on the Criticism of Suboxone,” November 16, 2021. https://www.crackdownpod.com/blog/Blog Post Title One-mt57a.
11
Mahr, Krista, and Ben Leonard. “‘Untreated’: Patients with Opioid Addiction Could Soon Lose Access to Virtual Care.” POLITICO, June 20, 2022. https://www.politico.com/news/2022/06/20/opioid-addiction-telehealth-00040568.
12
USAID Vietnam. Patients Receive Methadone Treatment in Dien Bien. November 1, 2012. https://commons.wikimedia.org/wiki/File:Patients_receive_methadone_treatment_in_Dien_Bien_(8231970528).jpg.
13
Treatment, Institute of Medicine (US) Committee on Federal Regulation of Methadone, Richard A. Rettig, and Adam Yarmolinsky. Methadone Diversion Control. Federal Regulation of Methadone Treatment. National Academies Press (US), 1995. https://www.ncbi.nlm.nih.gov/books/NBK232116/.
14
Crackdown Podcast. “Psychoactive Swap,” September 22, 2022. https://podcasts.apple.com/us/podcast/crackdown/id1450566001.
15
Obermeit, Lisa C., Jordan E. Cattie, Khalima A. Bolden, Maria J. Marquine, Erin E. Morgan, Donald R. Franklin, J. Hampton Atkinson, Igor Grant, and Steven Paul Woods. “Attention-Deficit/Hyperactivity Disorder Among Chronic Methamphetamine Users: Frequency, Persistence, and Adverse Effects on Everyday Functioning.” Addictive Behaviors 38, no. 12 (December 2013): 2874–78. https://doi.org/10.1016/j.addbeh.2013.08.010.
16
Cook, Jon, Martyn Lloyd-Jones, Shalini Arunogiri, Edward Ogden, and Yvonne Bonomo. “Managing Attention Deficit Hyperactivity Disorder in Adults Using Illicit Psychostimulants: A Systematic Review.” Australian & New Zealand Journal of Psychiatry 51, no. 9 (September 1, 2017): 876–85. https://doi.org/10.1177/0004867417714878.
17
Wetsman, Nicole. “CVS Will Stop Filling Cerebral and Done Health ADHD Med Prescriptions.” The Verge, May 25, 2022. https://www.theverge.com/2022/5/25/23141069/cvs-controlled-substance-cerebral-done-prescriptions.
18
Srivastava, Anita, Meldon Kahan, and Maya Nader. “Primary Care Management of Opioid Use Disorders.” Canadian Family Physician 63, no. 3 (March 2017): 200–205. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5349718/.
19
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20
Szalavitz, Maia. “Opinion | Why Forced Addiction Treatment Fails.” The New York Times, April 30, 2022, sec. Opinion. https://www.nytimes.com/2022/04/30/opinion/forced-addiction-treatment.html.
21
Smith, Jordan Michael. “The Jailing of Jesse Harvey.” Type Investigations, March 16, 2022. https://www.typeinvestigations.org/investigation/2022/03/16/the-jailing-of-jesse-harvey/.
22
Ravndal, Edle, and Ellen J. Amundsen. “Mortality among Drug Users after Discharge from Inpatient Treatment: An 8-Year Prospective Study.” Drug and Alcohol Dependence 108, no. 1 (April 1, 2010): 65–69. https://doi.org/10.1016/j.drugalcdep.2009.11.008.
23
“Assessment of Massachusetts Opioid Related Deaths: Preliminary Findings.” Massachusetts Department of Public Health, July 1, 2016. https://d279m997dpfwgl.cloudfront.net/wp/2016/08/DPH-Legislative-Report-Ch.-55-Status-Report.pdf.
24
Graulau, Bianca. “Floridians with Addiction Are Going to Jail Instead of Rehab in Pinellas County.” wtsp.com, July 19, 2018. https://www.wtsp.com/article/news/local/floridians-with-addiction-are-going-to-jail-instead-of-rehab-in-pinellas-county/67-575443050.
25
Dadiomov, David, Rebecca Trotzky-Sirr, Andrew Shooshtari, and Dima M. Qato. “Changes in the Availability of Medications for Opioid Use Disorder in Prisons and Jails in the United States during the COVID-19 Pandemic.” Drug and Alcohol Dependence 232 (March 1, 2022): 109291. https://doi.org/10.1016/j.drugalcdep.2022.109291.
26
Weizman, Shelly, Taleed El-Sabawi, Joanna Perez, Melissa Baney, and Isaac Manoff. “National Snapshot: Access to Medications for Opioid Use Disorder in U.S. Jails and Prisons.” Georgetown Law O’Neill Institute, July 28, 2021. https://oneill.law.georgetown.edu/publications/national-snapshot-access-to-medications-for-opioid-use-disorder-in-u-s-jails-and-prisons/.
27
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