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Drug treatment: Points of agreement and difference

I agree with Gary Norman that substance use disorder (SUD) is a treatable disease and that stigma continues unabated. However, I disagree with his commentary on two points.

Regarding the June 23 Community Voices commentary titled “On the war within drug treatment,” by Gary Norman:

I agree with Norman that substance use disorder (SUD) is a treatable disease and that stigma continues unabated. However, I disagree on two points: his depiction of the “war” within drug treatment and use of the term “harm reduction” when applied to clinical care.

Dr. Mark Willenbring
Dr. Mark Willenbring
There is no “war” within drug treatment, at least among those providers who care about scientific research. Given his affiliation, I assume he is referring to treatment for opioid use disorder. Treatment for opioid use disorder always involves a recommendation for medication, specifically for methadone or buprenorphine maintenance. Both substantially reduce death and disability from this highly disabling condition, freeing up the energy that went into their addiction into more productive activities. There is no scientific controversy about this approach; it is the only one that works.

Abstinence-based rehabs always fail miserably and there is not one good study documenting that it does work. Ideology trumps scientific findings though throughout the U.S. drug treatment industry and the criminal justice system. If the justice system stopped making people go to rehab, the entire industry would collapse overnight. It is really a matter of “who are going to believe, the science or my lyin’ eyes?”

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Harm reduction is a pragmatic drug policy that results in overall reduction in harms from both the SUD and the treatment process. However, it has no place in clinical care. Medication assisted treatment (MAT) could be applied to any medical condition: cancer, asthma, and depression are examples. But for those diseases it is simply called “treatment.” We ought to jettison the term MAT completely for SUD as well. A basic mistake that was made in the 1960s continues to this day: acute rehab for a chronic illness.

Modern treatment is long-term because the disease is long-term. It is simply not possible to develop recovery skills while one is in a residential rehab program. The work starts when a person hits the street. At Alltyr Clinic, we “don’t just call addiction a disease, we treat it like one©” and so we treat people for as long as it takes. It is time to fully integrate behavioral care, to provide addiction and mental health treatment all the time and at the same time. And the way to do that is to make affordable chronic care management to anyone who wants it.

Mark Willenbring, M.D., is an addiction psychiatrist and CEO of Alltyr: Transforming Treatment for Addiction, a clinic for people with SUD.