We Still Have a Ways to Go

Very excited to feature a post written by Paula DeSanto, Founder and President of Minnesota Alternatives and a leader in the movement to bring paradigm change to chemical dependency and mental health treatment in Minnesota. Thank you, Paula

We Still Have a Ways to Go

Four years ago I was inspired to open a clinic to help people with substance use issues because of the many, many stories I was hearing about ineffective and often times, harmful treatment.

While we are making progress with embracing more person-centered, stage matched interventions; I continue to have experiences that affirm how far we still have to go.  For example:

I was training a large group of clinicians and practitioners about person-centered care, and we were having a very spirited discussion about why drug and alcohol counselors seem compelled to report their clients use to probation officers.  I have worked as a mental health professional for over 2 decades and mental health clinicians don’t share this compulsion.   In fact, I can’t recall any MH worker ever thinking that this was their professional responsibility.

As this discussion progressed, a man raised his hand and offered a useful perspective.  He commented, “I worked as a probation officer for over 8 years, and throughout that time, we always thought of addiction providers as extensions of us.  There was a strong sense of “we – they” and the counselors job entailed trying to catch the clients using.”

Why do drug and alcohol clinicians think their job includes the role of a correctional officer?

No wonder clients “go underground” in treatment and say whatever they think others want to hear.

Another example:

I was interviewing a young woman who smoked a large quantity of cannabis daily and her parents were very concerned about her well-being.  She had been in treatment previously including some very prominent programs.   I asked this young woman why she smoked pot but before she had a chance to answer her mother jumped and stating, “She smokes because she has a brain disease, and her disease is controlling of her life”.

I again asked the young woman why she smokes, and she proceeded to explain that she smokes to relax especially at night before bed. What unfolded was a discussion about other motives for use and exploration as to whether this young woman even thought she had a problem.

A few days later her mother called me and shared this comment:

“My daughter has been in some of the best programs in the state and I have never heard anyone ever ask her why she uses.  She has always been told that she has a brain disease and they have the fix for it.”

“Kudos to you for asking.”

Buprenorphine: 4 Counseling: 0

It hasn’t been a good couple years for counseling in the buprenorphine treatment literature. Yet another study, authored by a team led by the venerable Walter Ling, and currently available in Addiction Journal’s “early view” section online, has shown that counseling adds nothing to buprenorphine maintenance, in terms of measured outcomes. By our count, this makes four consecutive studies to show basically the same thing: counseling, while by no means harmful, has not been shown to add anything to buprenorphine maintenance in opioid-dependent patients without significant co-occurring psychiatric disorders.

Ling, et al.’s study is arguably the most convincing study yet. The team performed a randomized control trial in which patients were randomized to one of four behavioral treatment conditions, as adjuncts to buprenorphine maintenance: cognitive behavioral therapy (CBT), contingency management (CM), both CBT and CM, and no behavioral treatment. Counselors were master’s-level trained counselors who met with patients weekly for the initial phase of the study.

The results showed no differences in opioid use after the behavioral treatment phase, during the second (medication-only) phase, or at follow-ups at weeks 40 or 52. In addition, there were no statistically-significant differences in any of the secondary measures (retention, other drug use, withdrawal and craving, addiction severity index ratings, and adverse events).

Interestingly, there were differences in reported treatment satisfaction ratings. While the majority of participants reported being “very satisfied” with treatment, and 85% reported Suboxone was “very effective”, just 60% reported that their behavioral treatment was “very effective”. On the other hand, 21% of the no-treatment group reported that their behavioral treatment was “not effective”, compared to 3% of the CBT group and 0% of the CBT + CM group.

As a student of behavioral health counseling, this science is particularly hard to swallow. However, it does seem to affirm the fact that, for patients with opioid-use disorders, ensuring easy and affordable access to maintenance medications is currently our best and most important tool for their treatment.

What do you think?

Is Maintenance the Best Therapy for Opioid Addiction?

Ian McLoone	6:30 PM (4 hours ago)
to me

Mark

I have been having some heated discussions lately about maintenance and the science around it. A lot of people say, "well reduced drug use is great, but what about quality of life?" For example, the studies comparing buprenorphine with and without counseling - there's no difference in outcomes, but those outcomes don't measure QoL. I did some research, and most of the studies I saw found improvements, but in the case of methadone, the improvements all occurred in the first 30days of Tx. Just wondering what you say about this perceived lack of QoL in the literature. 

Thanks

Mark Willenbring	10:57 PM (3 minutes ago)
to Ian

QOL measurement is a conundrum, very difficult to measure, since it's a perception, an interpretation, and doesn't correlate well with more objective measures of function or discomfort. 

I think their argument is simply a defensive one. The counterargument is that many more people who are treated with abstinence-based therapies relapse and die. Dozens of studies, internationally. What kind of QOL do dead people have?

The fact is, the ball is in their court: if they can prove that overall QOL is better (as well as survival) with abstinence-based treatment, terrific. If not, shut the heck up. If you reject a scientific finding on ideological grounds, say so. It's fine to assert: "Yes, more people use fewer drugs and fewer die if they take medication, but they aren't "really sober", they haven't "spiritually grown. Therefore, the goods of less drug use, more remission and fewer deaths are outweighed by a moral argument that their recovery is false. It is better to die than to take medication, because maintenance is not morally acceptable." That's a potentially valid position if you agree with their assumptions, which I obviously do not.

But don't argue that the findings aren't what they are because you don't like them. More people recover using medications, fewer people have legal, job, medical or social problems, and fewer people die with medication. These are established facts that cannot realistically be challenged, other than by rejecting current scientific methods and a broad international consensus of researchers and senior clinicians, not to mention the World Health Organization, the National Institute on Drug Abuse, the VA and DOD, and the CDC. I think the burden on the other side is formidable.

As Bernard Russell said, "When the facts change, I change my mind. What do you do, sir?"

Mark