Addiction Treatment

We must define recovery (and its subsets)... Now

At a recent SECAD conference, I had the honor of sitting on a panel with some of the finest minds in the addiction field. We were there to discuss the topic "Is Buprenorphine Maintenance Recovery?" The panel seemed to agree that treatment was distinct from recovery, that treatment is a vehicle for recovery, and that treatment is an action directed by professionals.

We disagreed as to what recovery is. It struck me as odd that after 50 years of having a treatment industry, we cannot define the core concept that we hope to instill in our patients. Until recently, no one has taken on this difficult task. But the time appears to be upon us. In September 2005, the Center for Substance Abuse Treatment hosted the National Summit on Recovery. The definition of recovery was one of the many tasks at hand. That consensus report from the conference stated: "Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence and improved health, wellness and quality of life.[1]" One year later across the U.S., the Betty Ford Institute gathered together research and industry experts to better define recovery. A consensus statement from that group stated: "Recovery is a voluntarily maintained lifestyle comprised of sobriety, personal health and citizenship.[2]" The consensus panel report goes on to state: "Sobriety refers to abstinence from alcohol and all other nonprescribed drugs" Bill White authored a conceptual article in the same issue of the Journal of Substance Abuse Treatment dedicated to this conference; in it he discusses the tricky issue of abstinence and recovery. He suggests a term "moderated recovery" for individuals who may not have the severest form of alcohol and drug abuse and who are able to curtail their use to the point of an improved overall life

This all begs the question "Why is the definition of recovery such a big deal at this point in our history?" The answer, I believe, is that we are at a time of crisis in the field of addiction treatment and research. I hope to convince each of you of the urgency of our situation; every one must weigh in on the definition of recovery to ensure we reach a clear and common consensus.

To examine why we are here, we have to review recent history. I see at least two reasons we are in this dilemma. The first has to do with the increased public attention and research on addiction as a brain disease. The second is the increased use of medications, addicting and not, in the mainstream addiction treatment market.


Changes in the Treatment Landscape

Patients in methadone treatment have a distinct treatment category, called Opioid Maintenance Therapy (OMT). OMT is effective and life saving. Patients remain on methadone for prolonged periods of time; they are "in treatment" for this time. In the recent past, it was less common to use the term "recovery" with methadone patients because they are continuously "in treatment."

Abstinence-based programs, in contrast, have used a model where patients "go to treatment" and if they continue with abstinence and "work the program" then they are "in recovery." More completely stated, one was in recovery if they remained abstinent and engaged in an ongoing process of self exploration that was guided by working the 12-steps, going to meetings and other spiritual activities, and listened to the advice of others. Parenthetically, Dr. Tom McLellan has spent the past several years trying to teach us that this model has contributed to the public's perception that the addiction treatment industry is ineffective. We have, he admonishes, chosen an acute care model for the treatment of a chronic disease.

The addiction treatment industry has been moving ever so slowly towards science and accountability. These forces demand we define our terms more precisely. But other changes are afoot. New medications, designed for the treatment of addictive disorders, induce another type of change in the system. Some of these medications assist in sobriety maintenance (naltrexone and acamprosate). Other medications assist the patient with the dark journey from the compulsive use of opioid drugs to an improved life, one with balance (methadone and buprenorphine). Almost everyone agrees that our increased understanding of the neuroscience and resultant drug development is a wonderful addition to the treatment of addiction. Nevertheless, advances in the science of addiction challenge our definitions and closely held convictions. They have a dark side.

Methadone proponents have taught us that patients can be maintained on a drug that all agree is addicting by its very nature and, on that drug, the patient's quality of life improves. If a methadone-maintained patient remains free of opioid and other addicting drugs, they can return to work, repair the family chaos produced by their illness and develop hope for the future. In fact, data shows that methadone-maintained patients improve even if they decrease, but do not stop using. Abstinence-based clinicians continued to point their fingers at the methadone patients and say: "But they are still on drugs." Right or wrong, this finger wagging comes partly from the stigma of the methadone delivery system and partly because methadone is itself an addicting drug. The effects of methadone decrease, but do not disappear with time in treatment. A low level chronic drug effect continues, including mild sedation, euphoria after a dose, and motor slowing. Most abstinence-based clinicians agree that methadone maintenance works, but they remain concerned about the effects of methadone itself. Some methadone-maintained patients continue to consume alcohol and other drugs. More importantly, the methadone maintenance in the United States is plagued by a stigmatized delivery system. Patients on methadone are shackled to the clinic, often returning every day to "get their dose."

Things became a bit fuzzier in the addiction world with the introduction of oral buprenorphine (Subutex and Suboxone). First, some of the side effects of methadone are milder with buprenorphine. Second, thankfully, the delivery system of buprenorphine is more humane. Any physician who has undergone a brief training and applied for a special DEA license can write buprenorphine prescriptions through their office. The patient goes to their local pharmacy to pick up the prescription, and feels less stigmatized as a result. Thirdly, almost every addiction medicine specialist writes for buprenorphine in some manner, some for detoxification only, some for detoxification and maintenance. The social and regulatory wall of separation between maintenance-based programs (formerly methadone programs) and abstinence-based programs has fallen. Some treatment programs mix their maintenance-treated patients with opioid addicts who have completely withdrawn from all drugs-patients who are abstinent. Buprenorphine has special properties that make it very desirable as a detoxification agent (it is very difficult to overdose on the drug) and a maintenance drug (if you increase the dose it acts more like an antagonist than an agonist). But it is still a μ (pronounced "mu") receptor partial agonist and, as such, has the effects of any μ agonist (euphoria as well as a quelling of disquieting physical and emotional pain).


What is Recovery?

When we mix traditional abstinence-based recovery with patients who are maintained on buprenorphine to help them remain off of opioid drugs, confusion ensues. Patient A who is drug free is "in recovery." Patient B who is free of street opioids and other mood altering drugs but remains on buprenorphine is "in recovery." Are these two patients in the same state? I think not. Neither state is more or less valuable or credible, and may not even be more desirable, but they are different. If you don't believe me, then take patient A and put him on buprenorphine, or take patient B and take him off buprenorphine. Then ask "do you feel qualitatively different?" The states are substantively different. The life goals and the quest for exploration of our emotional self are different in these two treatment groups. The buprenorphine-maintenance group is focused on getting life back on track and stopping the destructive cycle of using. The goal is more pragmatic, less abstract (and as a result more practical). The abstinence-based group often has a more difficult road. Removing the soft pillow of the opioid drug creates an intrapsychic (or spiritual) crisis. A recovery state can only be had in this group after walking through the dark places of the soul.

What worries me is this dilution of the term "recovery". Unless we become very clear about our definitions, we are sliding down a slippery slope. I need to be very clear that this does not mean that I think buprenorphine maintenance is wrong. Buprenorphine detoxification and maintenance is a wonderful addition to the treatment of addiction in the United States. This is simply a time for more clarity in our nomenclature. The word "recovery" is part of the public lexicon. It has taken decades to educate the general public about our disease and its treatment, and if we do not refine our mission and message with consistent terms, we run the risk of returning to the previous era of misunderstanding and prejudice.

One way out of this dilemma is to create two subsets of the state of "recovery", one called "abstinence-based recovery" and a second called "medication-assisted recovery." Being clear at a time when our field is evolving is critical. Having two categories does not imply that one state is superior to another, as some have suggested. They are, however, different. In either case, it is critical that we do not use "recovery" as an outcome measure. Recovery in any of its forms is a path not a destination or outcome. Outcome measures for any form of treatment must be quantifiable; examples include medical health, level of criminal behavior and life satisfaction. Recovery is the way, not an outcome measure and clearly not a place.

Now is the time to be clear about what we do and where we are heading.

[1] Center for Substance Abuse Treatment. (2007) National Summit on Recovery: Conference Report. DHHS Publication No. (SMA) 07-4276. Rockville, MD: Substance Abuse and Mental Health Services Administration.

[2] BFI Consensus Panel What is recovery? A working definition from the Betty Ford Institute Journal of Substance Abuse Treatment 33 (2007) 221-228

[3] White, W. Addiction recovery: Its definition and conceptual boundaries Journal of Substance Abuse Treatment 33 (2007) 229-241


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