Improve Treatment

There is a stark contrast between the lifetime nature of substance use disorders and the short-term treatments offered to substance users.  And it is not surprising that return to the use of alcohol and other drugs following treatment is the most common outcome. With such short periods of treatment, little follow-up, and limited recovery support, it can be hard for those with a disorder to overcome the substances that have hijacked their brain and press for continued use.

For nearly a decade IBH has studied the nation’s state-run Physician Health Programs (PHPs), publishing eight academic articles on this distinctive form of care management. Long-term outcomes from these programs show that physicians with opioid use disorders have the same sustained excellent outcomes as physicians dependent on drugs other than opioids – including alcohol– without using methadone or buprenorphine, known as opioid substitution treatment (OST). Instead participants in the PHPs complete relatively brief (30-90 days) intensive abstinence-based treatment, followed by five years of intensive monitoring for any use of alcohol or other drugs and immersion in Alcoholics Anonymous (AA), Narcotics Anonymous (NA) and other community-based recovery support programs. IBH currently is studying follow-up results of how a cohort of physicians are doing five years or more after successfully completing a substance use disorder monitoring contract with the PHPs.  IBH has labeled this care management system, and similar programs in the criminal justice system, the New Paradigm for the management of substance use disorders. 

It can be argued that outcomes from the PHPs are unique because their participants, i.e., physicians, are an irrelevant, special group.  Not only is this patient population highly educated with correspondingly high incomes, but they stand to lose the source of their livelihood – their medical licenses – should they not comply with the zero tolerance program of abstinence required by the PHPs.  For that reason, IBH is studying programs within the New Paradigm that share many similarities with the PHP model that work with very different populations.  A number of these programs showing similarly impressive results exist within the criminal justice system, such as HOPE Probation and South Dakota’s 24/7 Sobriety Project. Though focused on an entirely different population than physicians, like the PHPs these initiatives use the leverage of the criminal justice system to require compliance, including abstinence from drugs and alcohol, of their participants.  Again, because sanctions are involved, the criticism has been that such programs do not translate to larger addicted patient populations, including those addicted to opioid medications, where there is no leverage similar to the leverage in the PHP and criminal justice programs.  

To answer this skepticism about the generalizability of this model, IBH is working with several treatment programs serving general addicted patient populations using the New Paradigm. The central organizing feature of programs using the New Paradigm is the long-term monitoring with contingency management at modest cost to achieve sustained abstinence and the significant improvements in life that are captured in the term “recovery”.  The New Paradigm mirrors the recent dramatic reinvention of heath care seen in other fields, with its focus on lifelong chronic disease management.  More information about these and other programs can be found in the 2014 report, The New Paradigm for Recovery: Making Recovery – and Not Relapse – the Expected Outcome of Addiction Treatment.

IBH President Dr. Robert DuPont discusses the five-year recovery standard at the Hazelden Betty Ford Foundation.

In an interview for The Opioid Research Institute's Opioid Watch, IBH President Dr. Robert DuPont was asked, To be clear, for treatment of opioid addiction you do favor, don’t you—or do you—medication-assisted treatment over just a 12-step program without medication? 

Dr. DuPont answered: 

"I define this as the war in addiction treatment. The war is between the medication-assisted treatment and the “drug-free” treatment...

The drug-free programs need to offer medications as options. At the same time, medication-assisted treatments need to integrate AA and NA, and other community support, into their programs. And both programs that use and do not use medications need to be judged on their abilities to produce lasting recovery.

We need to, all together, recognize that when a patient is taking buprenorphine or methadone or naltrexone as it’s prescribed, that’s a medicine and not a drug. Use of medications as directed and no use of alcohol or other drugs of abuse needs to be defined by everyone as fully compatible with recovery.

We need to end the war between the treatment modalities for the sake of our patients and to deal with the deadly drug and overdose epidemic our nation faces today." 

The IBH report A New Agenda to Turn Back the Drug Epidemic supports the recommendations in the 2016 Surgeon General’s Report and: 

  • Underscores that addiction is a serious chronic illness and promotes the development of a modern continuum of public health care for addiction;

  • Recognizes that abstinence is an achievable, high-value outcome, both for prevention and treatment;

  • Acknowledges that there is a paucity of current models for systematic integration of addiction treatment and general healthcare; and,

  • Encourages the identification of promising models and the promotion of innovation to achieve the goal of sustained recovery, defined as no use of any alcohol or illegal drugs other than medicines that are prescribed and monitored to sustain recovery.

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