How Many More Data Points Until We Reach the Tipping Point?

A disturbing study was reported in Addiction Professional recently with the headline “60% of Residential Programs Offer No MOUDs.” The study cited was published in JAMA Network Open in February. My career has included work in the addiction field, and I have seen various medications used for detoxification for opioid use disorders (OUDs). The results of this survey surprised me.

The research on medication-assisted treatment (MAT) establishes that we have three medication types, each chemically distinct and effective, for detox and early treatment of OUDs. In fact, the JAMA article summarizes the evidence by stating that medications for OUD are considered by the medical community to be “the criterion standard in initiating and sustaining long-term OUD recovery.”

My surprise at the findings quickly gave way to a familiar feeling of sad acceptance. An understanding of the dilemma here starts with the reality that general medicine witnesses many years of delay between the validation and the broad implementation of evidence-based treatments. Behavioral healthcare adds stigma to this mix, and the JAMA article notes that addiction treatment is even more troubled:

Currently, there is no medical and/or behavioral standard of care for OUD across residential facilities, and the level and quality of care can vary greatly from one facility to the next.

This chasm between knowing “the criterion standard” and lacking a “standard of care” should not get lost in the technical language. Let us add one other perspective before exploring this. Marc Fishman, M.D. has noted that these maintenance medications have 6-month retention rates at or below 50%, comparable to the poor rates of adherence and retention for other chronic conditions like diabetes.

He argues we should improve these rates and get people into care earlier. Without a doubt, we need to move our interventions upstream. Waiting until people land in ERs or jails is hardly ideal, and so we need to establish the goal as using MOUDs along the care continuum. Unfortunately, today we are not stabilizing most people with these medications even within dedicated addiction treatment programs.

How many JAMA-type data points are needed? When do we reach the tipping point and get moved to action? We can debate the relative merits of treatment options, from 12-Step or SMART recovery groups to cognitive-behavioral therapies. Similarly, we can compare our three good choices for stabilizing OUD patients. Yet, why would treatment be offered without one of these effective medications?

The behavioral healthcare field should collectively own this failure of OUD patients. Our goal should be an embrace of science. We can tackle public perceptions only when this is firmly established. Executives throughout our industry should refuse to be intimidated by questions of their medical expertise. We will not overcome stigma one subspecialty at a time, nor by expertise alone.

Let us not focus on externals we cannot control. The conundrum is how a field scarred by stigma learns to function. One way is to hunker down in survival mode and cling to past strategies. As the JAMA article states clearly, the nature and the quality of care varies from one facility to the next. This inconsistent care is best explained by history and tradition, not by scientific evidence.

There are surely many reasons 60% of residential facilities offer no effective medications. Political, financial, and administrative rationales abound. Yet, those details are a distraction for now. We should also not get diverted into searching for better medicines. Better is always welcome, but good is being neglected today. Let us not curtail our outrage, nor tinker around the edges of the real problem.

Our outrage should provoke a commitment to fundamental change. We can start by ensuring people with OUDs get the right medications, but this should be an entry point. I have argued previously for clinical consolidation of the behavioral healthcare field. This consolidation can remove the scars of stigma by strengthening all specialties in our field and following the scientific evidence where it leads.

Imagine if an external authority refused to make the best medications available for patients. Managed care has certainly provoked outrage for actions of this sort. How, then, should we respond to decisions by colleagues, whatever their basis, to make critical medications unavailable? This is not a time for blame, but rather an opportunity to unite around a common commitment to science over tradition.

The final step in a new direction is alignment with the medical community. The historical separation between medical care and behavioral healthcare will not continue. This historical artifact is being erased daily with acquisitions by large medical corporations. Yet medical-behavioral collaboration is well justified on clinical grounds as well. Many factors are driving us to the primary care setting:

The primacy of behavior change in health status leads us to primary care as the setting for our services. These are the frontlines for the emergence of depression and other behavioral disorders. This is where people present somatic issues that originate in psychic stress. This is where health behaviors go largely unchecked as the catalyst for chronic (and hugely expensive) medical conditions.

The treatment of addiction in the shadows of the medical establishment will end one day, but the nature of that ending is uncertain. If we hope to move the detection and treatment of addiction upstream, then behavioral healthcare specialists must move into the primary care setting. If we hope to impact addiction before it is comparable to late stage cancer, primary care must be reorganized.

Physicians are familiar with how medications can become caught in political struggles. They remember the early years of treating HIV/AIDS. We now have effective medications for opioid addiction that are not getting to people in need. Interdisciplinary collaboration is never simple, but mutual support can be found with physicians of every specialty in overcoming obstacles to providing the best care.

Those obstacles can be found inside and outside professional ranks. A commitment to treatment and recovery must be the unifying force. Our principles can sustain us for the long haul. Yet the immediate impetus for change comes from emotion. A flash of idealism now and then is great, but we will need a good dose of outrage to get moving and gain traction. Let us be moved by the 60%.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.