Medication-Assisted and Abstinence-Based Treatment Approaches Can Share Common Ground

Medication-assisted and abstinence-based addiction treatment programs are philosophical polar opposites, but providers from each end of the spectrum can learn from each other’s approaches, said Robert L. DuPont, MD, president of the Institute for Behavior and Health.

On Monday at the Rx and Illicit Drug Summit in Atlanta, Georgia, Dr DuPont, Cara Poland, MD, MEd, FACP, DFASAM, an associate professor at Michigan State University, and Gresha Eberly, CPRC, HEART Project manager at Michigan State, delivered a presentation on combining medication for opioid use disorders with 12-Step recovery support. Following their session, the trio spoke with Addiction Professional about conflicts between different treatment approaches and attempts at finding common ground.

Editor’s note: This interview has been edited for length and clarity.

Addiction Professional (AP): What do you see as being the biggest conflicts that are impeding the progress toward implementing elements of abstinence-based recovery into MOUD treatment and vice versa, the use of medications in abstinence-based treatment programs?

Robert DuPont: I think the main thing is everybody wants to be right, and it's hard to figure out that there are other people who are also right, and that's our message—the diversity of the experience and the diversity of the responses in medicine. There’s a tremendous desire for everybody to think their way is the right way and to be able to throw grenades at the other side about it. That really undermines confidence in everybody in that [area].

Cara Poland: I think one of the key things is that we want people to recognize that everybody's story, everybody's journey is different. And so, the important thing is not whether or not I'm right as a practitioner, or whether or not anonymous groups are right in abstinence-based programming, but what will work for that person in our community that we're trying to support in their healing process?

Gresha Eberly: I agree with both. Nobody recovers the same way. It depends on the person. And there's a huge divide between different pathways that people take, and I think that plays a big role.

AP: While everyone’s recovery journey is different, do you see common ground for those who are in an abstinence-based program and those in an MAT program?

CP: Everybody has the disease of addiction, so our goal when we work with our patients is to always offer them the menu of options. But I am no more the expert in that individual's life and what's going to fit into that person's life, whether we're talking about diabetes, whether we're talking about substance use. So, the goal there is to give people the menu of options, and help them figure out what they want to try first. Maybe they try a filet, and they really wanted a lobster tail. We might need to shift what is going to work for a person as they go through a lifetime of treatment.

Because even people who have been in recovery for years and decades, they still are working a program. They're still doing things to keep themselves healthy, as healthy as they can be, as a person with a lived experience with a substance use disorder. But we see that in all chronic illnesses. The success stories are the people that have figured out how to live their life with that illness, despite that illness, and to be better, bigger, stronger because they've overcome and found a way to live with their illness in a healthy, sustainable way.

RD: This is the only disease where when you get well, you're better than you were before you started. There is no other disease like that. I've been in the field for 55 years now, and the biggest thing that's happened over that is the emergence of a large recovery community. That wasn't there before—that is really exciting. There are many roads there and many ways to look at it. The 12-Step programs clearly state that recovery means no use of alcohol or any other drug of abuse. That's it. But recovery is more than that.

We understand that not everybody does what they need to do, but we work with them anyhow. … My thought is as long as we can be clear that the goal is no use of any of these drugs, I'm comfortable, but that's not always the case. People will carve out particular drugs. There is an “I'm not using an opiate, but I'm still drinking or using marijuana” kind of thing.

Another one is in the Alcoholics Anonymous or Narcotics Anonymous program. Your sobriety date is the last day you used any drugs. If you have 20 years of sobriety and you use alcohol for one day, you have a new sobriety date. Most people in medicine cannot abide that. That's not the way we think about it. What I find very interesting is that the people who take that view, it turns out it's the people in recovery. They have invented that. It's purely contrary to medicine. You wouldn't do that, but they do.

There are plenty of issues that are still challenging, but I think the idea, at least that we're interested in, is recognizing some of these differences and not having to beat the other guy into submission or say that they're wrong, but you just have a different way of looking at it.

CP: But I think they're all along the continuum, right? When we look at treating other chronic illnesses, if we look at asthma, we don't expect people never to have an asthma flare up because there will be environmental triggers. There are going to be unexpected things that pop up that may trigger their asthma. But we want to give them the tools to be able to prevent that as much as possible. We want them on their long-acting inhaler so they don't have as many flares. We want to give them a rescue inhaler so that if they do have a situation pop up that's unexpected, they can address that. We want to give people in recovery the tools so that if somebody does offer them that glass of alcohol or if they have an environmental exposure, they have the tools in their tool chest to prevent that episode of use or that relapse. But we also maybe want them on long-term methadone or buprenorphine or naltrexone to give them that brain stability and that safety net in the same way that we're giving people's lungs that stability when they're on a long-acting inhaler.

But it's going to look different for different people. It's going to look different for different people based on where their disease is, the severity of their disease. Not everybody with asthma gets the exact same treatment. We have to look at the individual and make sure that we are offering them what is appropriate for their disease state, knowing that it then has to fit into their life, and we can't dictate how that works.

AP: What can providers who are working in very different types of addiction treatment programs learn from each other to improve outcomes?

CP: When Gresha meets with my medical students. I always ask, what is the one piece of advice if you could give these kind of up-and-coming doctors, what would that be in terms of treating people with substance use disorder?

GE: Treat us like any other person, any other patient. Before our addiction, we were people, we were normal people and we're still that same person. Just treat us like you would any other patient and have just a little compassion and just treat us like a human being.

RD: I'd like to bring up something Gresha said when I was talking to her earlier: There's more wrong with someone who's using drugs than the fact that they're using drugs. A person in recovery has something more right than the fact that they're not using drugs. There is a character logic issue that is fundamental in this disorder, in terms of the active user and in terms of somebody in recovery. Most of my medical colleagues don't understand that because that's not thinking medically. But when you work with people who are in recovery, you see it and they see it. … One of the reasons that there is stigma against addiction because there are real problems, particularly an issue of honesty, would be an example of that. People who are dishonest, I understand. But that character logic aspect of it is very, very important, and it's more than using and not using.

Reference

DuPont R, Poland C, Eberly G. Voices of recovery: combining medication for opioid use disorders with 12-step recovery support. Presented at Rx and Illicit Drug Summit; April 10-13, 2023; Atlanta, Georgia.