In opioid use disorder treatment, there’s been a persistent (though not always acknowledged) tension between what’s good for public health and what individuals and their families want from treatment. I’ve written about it before. For public health, there’s plenty of evidence that MAT (medication assisted treatment) reduces illicit drug use, improves health and reduces crude mortality rates.
Meeting people with opiate use disorder who were in long term abstinent recovery from illicit and prescribed drugs changed my mind about what was possible. I suppose I have met hundreds of such people over the years. That’s a game changer. I worry that some prescribers don’t spend enough time with people in recovery.
Although there are substantial benefits to MAT, there are also problems: non-engagement with those who would benefit and timely access for instance. Then there are other issues too: stigmatisation of those on methadone, poor retention in treatment and how MAT fits in with the management of problem polysubstance use, including alcohol.
So, does MAT help patients achieve their wider goals – those person-important outcomes?
We don’t really know is the short answer. A systematic review published in 2017, found that health related quality of life measures are rarely used as outcomes in MAT research. When looked at from a recovery perspective, we have more evidence on the negatives that go than on the positives that arrive. There are studies showing improved quality of life, but we need more on whether people reach their goals and get improvements in the things that matter to them.
A small in-depth Norwegian study involving 7 women and 18 men on MAT found evidence of them being ‘stuck in limbo’ in terms of not moving on despite national guidance that the patient’s own goals ‘should be the basis of treatment’. These drug users were still engaged in illicit drug scenes. The researchers found four themes:
This popular claim lacks evidence and leads to poor policy.
The notion that drug addiction is a brain disease has become axiomatic. Around the globe aspiring health professionals treating substance abuse are indoctrinated with this belief, especially after the idea became popular in the 1990s. Its popularity extends far beyond the hallowed halls of academia. Both the May 1997 Time and the September 2017 National Geographic magazines were dedicated to the brain science of addiction. Numerous other popular magazines have run similar cover stories over the past two decades.
But after 20 years of research, one of us (Hart) saw that paradigm yielding dismal results. Meanwhile, behavioral research on outcomes after providing both animals and humans with attractive alternatives to drugs has yielded positive results regarding effective treatments, despite the lack of mainstream attention.
Despite this seemingly solid scientific consensus, there are virtually no data in humans indicating that addiction is a disease of the brain in the way that, for instance, Huntington’s or Parkinson’s are diseases of the brain. The existing paradigm is based on intuition and political necessity, not on data and useful clinical results. Yet the diseased-brain perspective has outsized influence on research funding and direction, as well as on how drug use and addiction are viewed around the globe. This situation contributes to unrealistic, costly, and harmful drug policies: If the problem is a person’s neurobiological state after exposure to a drug, then either the drug must be eradicated from society through law enforcement or an individual’s brain must be treated. In such a myopic approach, the socioeconomic and societal factors that contribute to drug addiction are considered a footnote in research, clinical practices, and policy, despite their apparent importance. (see also DRR: Dealing With Addiction)
“It’s not that difficult to overcome these seemingly ghastly problems [drug addiction]… what’s hard is to decide to do it.” Robert Downey Jnr (2004)
This is where assisted decision-making is imperative.
No matter how functional the regular drug user may appear, the drug addled brain has corrupted processes due to the presence and interference of psychotropic toxins. Whilst we may not be able to ‘arrest our way’ out of this issue, we will not be able to ‘treat our way’ out alone either. It is a more complete process, as with all behaviour change, that requires all educative and legislative measures coalescing into drug use reduction, not just attempting to reduce harms of a permitted drug use model.
This gives added weight to why a Judicial Educator is not only needed but is best placed to be engaged through problem-solving courts as a key circuit breaker needed to help facilitate drug exiting. Punitive action is not necessary, if these mechanisms are able to recalibrate the drug user into the recovery processes. But changing the status of drug use to ‘decriminalized’ is a step backwards in best-practice. It eliminates this vital, individual and community benefiting intervention and also increases drug use induced harms.
It is important to underscore that the current proactive and protective laws have not been used in any real punitive context for decades. They are part of a proactive framework – As the ‘Judicial Educator’.7
No criminal records need be recorded if the diversion path is embraced effectively.
The pro-drug lobby’s completely fallacious meme of ‘war on drugs has failed’ reverses the real causes and effects of drug harms and violence. There has been no ‘war on drugs’ in this nation since 1985. Instead there is an ever growing ‘war FOR drugs’10 as it continues to look to remove genuine tools that can bring best-practice drug use exiting outcomes and instead mislabels and propagandises these genuine efforts as ‘wars’ against drug users.
The removal of the protective legal vehicle that would otherwise compel people into treatment, will instead only assist in adding to, not only individual drug harms, but harms to our more vulnerable communities and their families – and particularly to our children.
Do these changes indicate that as a society there is more concern for tobacco users than illicit drug users? The latter deserve the same passionate assistance to exit drug use rather than any further enhancement or endorsement.
For the safety and future of not only the current drug user, but the protection of families and the most vulnerable in our community – our children – the legal status must remain unchanged. Yet re-tasked for better outcomes. The Dalgarno Institute is available to dialogue and assist in formulating this re-tasking.
It is important to glean all the evidence-based facts about models prior to profiling them as options, particularly models that have either failed or are being reviewed due to poor outcomes and/or just plain limited, inaccurate or misrepresentative data.
This is where assisted decision-making is imperative. The drug addled brain has corrupted processes due to the presence and interference of psychotropic toxins. The Judicial Educator actively engaged through problem-solving courts is the key circuit breaker needed to help facilitate the exit from this will diminishing haze. Punitive action is not necessary, if coercive mechanisms are able to recalibrate the dysfunction processes, through drug free recovery processes. This is why 'legalizing' drugs eliminates this vital, individual and community benefiting intervention and a care-less action for a society with increasing drug use induced harms.