A Call for a ‘Peace Plan’ to Properly Treat Opioid Use Disorder

(Part 1 of 2)

A session at the recent Rx Drug Abuse & Heroin Summit educated virtual attendees about the need for a “peace plan” between the different addiction treatment programs and the “many paths to recovery”. In this video, Robert Dupont, MD, Institute for Behavior and Health, Inc., Rockville, Maryland, discusses his recent session titled “Combining Medications With 12-Step Model Treatment” that he co-presented with Marvin D. Seppala, MD, of the Hazelden Betty Ford Foundation, Center City, Minnesota.

In the upcoming part 2 of this video, Dr. Dupont, who is also on the Rx Summit Advisory Board, discusses the 12-step-oriented model of addiction treatment and the need for it to “add medication as a fully respected, long-term option for patients with opioid use disorder”. He also discusses his goal to help the 2 treatment camps “stop fighting with each other” and his hopes that both can” work together in mutual respect”.

Read the transcript:

Hello and welcome. I am Robert DuPont, MD. I had a wonderful experience at the Rx Summit this year warning about the ongoing war in drug treatment between programs that use medications and those that do not.

Here is a peace plan to end that war for the benefit people with serious drug problems. This plan grows out of my work in addiction treatment since 1968. I was the first Director of the National Institute on Drug Abuse, and the second White House drug czar. I have been continuously engaged in treatments which use, and which do not use, medications for decades. Throughout that time, I have seen my own addicted patients, including in some families over three generations.

The world faces a serious drug epidemic that now is often thought of as the opioid epidemic. However, there are virtually no opioid users in the US who do not also use other drugs. When you look at overdoses, there is an average of 2 to 4 – and up to 11 – other drugs present at death in opioid overdoses. This deadly epidemic is not just about opioids. It is a polydrug problem and that distinction matters.

Our treatments for this polydrug epidemic fall into 2 distinctive categories. One started at the Hazelden Foundation in Center City, Minnesota in the late 1950s, with a 28-day residential program followed by patients going to Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) and other recovery support for years, often for their lifetimes. This approach is common in private, often insurance-funded, addiction treatment programs.

The other approach is medication-assisted treatment (MAT) which started with methadone in the late 1960s. MAT now includes buprenorphine and naltrexone. MAT is the major strategy for most public sector addiction treatment programs.

Those two approaches often battle one another in this war between treatment modalities. That war is destructive and unnecessary. It diminishes both approaches. The big losers are our patients and the public health.

I have great respect for both camps. Our country needs and benefits from both.

Start with MAT. It is important to recognize that all three medications only deal with opioids. There are no opioid use disorder (OUD) patients who just use opioids. Alcohol is often in the mix, as well as marijuana, cocaine, methamphetamine, and many other drugs. MAT attracts a lot of patients. Drs. Vincent Dole and Marie Nyswander, who started MAT with methadone, thought the methadone for a person addicted to heroin was analogous to insulin for a diabetic – that most patients would need to use methadone for their lifetimes. In practice some patients do use it for their lifetimes, but the vast majority do not. In one program I studied only 15% of the methadone patients were still there at the end of five years, including those who left and returned. Retaining that 15% of patients for five years is good, but there are a lot of people who have left.

In MAT programs there is often a feeling that the goal is to use “less” rather than no nonmedical use of opioids as well as no use of any other drugs. What’s to be done about the continued use of marijuana, alcohol, and other drugs in MAT?

The average stay for methadone treatment is about six to nine months. The average stay for buprenorphine treatment is about three to six months. For naltrexone, it is even shorter. Even though opioid use disorder is often a lifetime health problem.

Now look at the original drug-free, 12-step model of addiction treatment which aims at no use of opioids as well as no use of marijuana, alcohol, and all other drugs of abuse. These programs define the treatment goal as recovery, including but not limited to no use of alcohol, marijuana, or any other drugs.

Robert L. DuPont, MD has been a leader in drug abuse prevention and treatment for over 50 years. He was the first Director of the U.S. National Institute on Drug Abuse (1973-1978) and the second White House Drug Chief (1973-1977). From 1968-1970 he was Director of Community Services for the District of Columbia Department of Corrections. From 1970-1973, he served as Administrator of the District of Columbia Narcotics Treatment Administration. In 1978 he became the founding President of the Institute for Behavior and Health, Inc., a non-profit research and policy organization that identifies and promotes powerful new ideas to reduce drug use and addiction. A graduate of Emory University, Atlanta, Georgia, Dr. DuPont received an MD degree in 1963 from the Harvard Medical School, Boston, Massachusetts. He completed his psychiatric training at Harvard and the National Institutes of Health in Bethesda, Maryland. Dr. DuPont maintains an active practice of psychiatry specializing in addiction and the anxiety disorders and has been Clinical Professor of Psychiatry at the Georgetown University School of Medicine since 1980. 

His most recent book is Chemical Slavery: Understanding Addiction and Stopping the Drug Epidemic published in 2018.  

For more about Dr. DuPont’s work and the Institute for Behavior and Health, Inc. visit www.IBHinc.org, www.StopDruggedDriving.org, and www.OneChoicePrevention.org.