Why Treatment Fails, Part 3 of 4 by David Gerber

Medication has become the first line of defense in addiction treatment.

As we have moved to a more medical model of treating substance use disorders, we use medications that can get the user high in the process of providing substance use disorder treatment. Like the harm-reduction model, the prevailing thought for using medication is that if the problem can be medicated as quickly as possible, people are less likely to die from overdose. In some states, it is a requirement to offer medication assisted therapies to those abusing opiates and alcohol at the onset of treatment.

I have been in the field of addiction treatment for over 30 years. When I ask my clients “how many of you misused the medications prescribed” nearly all of my clients report that they have. According to an article published in the Journal of American Medical Association in October, 2021*, 25% of people who take Suboxone (one of the 3 major forms of medication assisted-treatment therapies) misuse it. Many consider this a successful statistic- only 25% misuse. Where else in life is that acceptable? Would you go to a restaurant that says we only undercook your food 25% of the time? Would you go to a mechanic that says 75% of the time we fix your car, right? How about going to a surgeon that says he performs a tonsillectomy correctly 75% of the time?

However, the truth is that by the time a client enters into formal addiction treatment, they are misusing this medication well over 50% of the time. Even worse, these clients who misuse Suboxone are legally prescribed the medication and are selling it for other drugs like heroin. This means that if a client happens to be on some form of government assistance like Medicaid, taxpayers are now indirectly perpetuating and funding addiction.

Some people in addiction treatment still consider Methadone—a medication that acts like a synthetic form of heroin—the gold standard of medication-assisted therapies. The goal of methadone is to satiate the desire to use other drugs. However, many clients continue to use other drugs like heroin, while taking methadone, which leads to increased doses of methadone. In many cases, the doses are so high that the ability of the client to lead a normal life is significantly diminished.

I have interviewed many clinicians who come from the field of methadone, and have found that time after time, clinicians report a success rate of methadone treatment to range between 5% and 10%. This strategy, in my view does not seem to be working.

While most of the pharmaceutical companies indicate that their medications like suboxone and methadone work best when combined with treatment and therapy, many of the clients who are abusing these prescribed medications fail to show up for treatment appointments, yet programs and providers are urged to continue to medicate clients. This practice indicates that the medication is more important than the treatment, which is a dangerous supposition. The pharmaceutical companies have convinced government agencies that their medications are saving lives, while in at least 25% of the population that are medicated, the misuse of these same medications may only lead to delaying death.

Please understand that I am not saying that these medications are not saving lives. There are thousands of people for whom prescribing medication assisted therapies works, and works well.  

Injectables like Vivitrol are extremely difficult to misuse. Unlike Methadone and Suboxone, Vivitrol blocks opiate receptors preventing the individual from getting any euphoria, even when they attempt to use drugs like heroin, which reduces the purpose of using. Because it’s a monthly injection and doesn’t get the person high, it has no street value and can not be sold for drugs.

The bottom line is that medication assisted therapies, while in theory are helpful, in practice they have minimized the role of counselors and social workers who have been trained to help those suffering from substance use disorders. In many cases it undermines the value of clinical efforts and trained professionals. People and politicians all over the country are indicating that we need to give people more access to medication assisted therapies, however drug overdoses have increased, not decreased while the rate of people on these medications continues to rise. We have got to do better.

* https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2785011