The Beginning of the End of the Abstinence Rule?

By Maia Szalavitz 11/08/12

When Hazelden realized traditional treatment for young opiate-painkiller addicts was failing, it introduced maintenance therapy. Only a week later, the backlash has begun.

Historic Hazelden photo

The reaction to the news last week that Hazelden will be using medication-assisted treatment—including the maintenance drug, buprenorphine (Suboxone), potentially indefinitely for some patients—has been intense. “Hell froze over,” one tweeter responded, expressing shock that the granddaddy of abstinence-based treatment could make such a big change. “It’s about time,” said Dr. Charles O’Brien, director of the University of Pennsylvania’s prestigious Center for Studies on Addiction, and one of the field’s most eminent researchers. The head of the National Institute on Drug Abuse, Dr. Nora Volkow, also praised the decision.

But while people familiar with the incontrovertible data showing that maintenance saves lives are singing Hosannas and hoping that Hazelden’s shift foretells a sea change, those who believe that abstinence is the only acceptable treatment outcome aren’t surrendering without a fight. And public misperceptions about intoxication from maintenance medications could support this backlash if not appropriately addressed.

A report published in the trade publication Addiction Professional says that representatives from several major private residential treatment programs—including the Caron Foundation, Father Martin's Ashley and, bizarrely, Hazelden itself—met in October in Nashville to develop a “white paper” aimed at shoring up support for abstinence-only treatment and demonstrating that residential care is more effective than outpatient treatment for opioid addiction. While those involved said that they don’t necessarily oppose buprenorphine maintenance, one of the paper’s eight points of agreement will be that abstinence is the “desired” outcome.

Addiction Professional claims that former Obama deputy “drug czar” and longtime University of Pennsylvania addiction researcher A. Thomas McLellan will issue the white paper. But he says that he is not involved in the project. On buprenorphine and Hazelden, he adds, “Tell me another area of medicine where willingness to use an FDA-approved medication is a bad idea. Tell me another area where it makes news."

Other signs of backlash can be seen in the responses to the articles published about the change, in which commenters cite negative anecdotes about maintenance and claim that the push for change is just another example of pharmaceutical industry pressures unduly influencing psychiatry. Yet The World Health Organization, The US Institute on Medicine and even the office of the “drug czar” all see maintenance treatment as a crucial option and as the one most likely to save the lives of long-term opioid addicts. And the evidence favoring maintenance comes largely from government-funded research on the cheap generic medication methadone, which makes the idea of excess industry influence somewhat laughable. Methadone was introduced in the '60s, while Suboxone got FDA approval an entire decade ago.

At least half a dozen former Hazelden patients have died from overdose—a rate that shocked the rehab.

Of course, no one—let alone Hazelden—actually argues that Suboxone should be used for everyone or that abstinence-based treatment shouldn’t be available to people addicted to heroin or prescription pain relievers. Hazelden’s decision to offer maintenance was made because of the enormously high relapse rate it saw among opioid-addicted people leaving residential care, a group for whom abstinence-only treatment clearly wasn’t working. In recent years, at least half a dozen former Hazelden patients have died from overdose—a rate that shocked both the renowned rehab’s leadership and its counselors. Prior to the recent rise in prescription drug addiction, only 20% of their patients were addicted to opioid drugs; now, among young patients, the rate is 41%.

It was those frequent relapses and deaths that made Hazelden reconsider the treatment it provides. According to its chief medical officer, Dr. Marvin Seppala, the knowledge of those bad outcomes resulted in far less resistance to the decision to allow maintenance than he had expected from those steeped in 12-step treatment. During the 10-month period in which Hazelden worked on the change, it held numerous meetings and trainings to help staff get on board and address their concerns.

But how could an organization that had abstinence at its very core even begin to embrace maintenance? In Narcotics Anonymous (NA), the 12-step program for opioid addicts (as well as stoners and coke heads), people on methadone maintenance have traditionally not been considered to be “in recovery,” and their “clean time” typically wasn’t even allowed to start to be counted until they stop maintenance. Some meetings won’t even allow people taking maintenance medications to speak, because they are seen as active users who simply have substituted one drug for another.

There are, however, certain 12-step programs that do support recoveries that don’t involve total abstinence. Obviously, people in Overeaters Anonymous (OA) cannot entirely refrain from eating, and requiring participants in sex addiction programs to give up all sexual relationships isn’t much more realistic. Instead, people in these programs come up with definitions of abstinence that work for them. For example, some people in OA identify “trigger foods” that aren’t safe for them to eat and consider doing so a relapse; people in sex addiction programs may stick to monogamous relationships only. “If you think about overeaters or sex addicts, they have to define their own recoveries really specifically and define abstinence for themselves,” Seppala says.

“Maintenance failures” are visible at the clinic, while abstinence failures are not at the rehab.

Hazelden, therefore, will consider people who are taking maintenance medications as prescribed as being “in recovery” from the day they start therapy and abstaining from nonprescribed drugs. Relapse will involve using in any way that deviates from medical advice. There is a precedent for this view of recovery: a 2007 panel convened by the Betty Ford Institute concluded that people who are on maintenance medications who follow medical instructions may be considered in recovery, although ironically, the Betty Ford Center itself still rejects maintenance medication. The maintenance-supportive definition is also used by the advocacy group, Faces and Voices of Recovery (FAVOR).

And in yet another sign of just how radically the addiction world is changing, NA itself seems to be softening its stance. “Our policy is a little convoluted,” concedes Jane Nickels, public relations manager for NA World Services, while stating firmly that “our basic philosophical foundation is abstinence.”

Here’s how weird it gets: an NA publication written in the ’80s and updated in the ’90s said both that “the only requirement for membership is a desire to stop using” and also that meetings can legitimately limit those on maintenance medication from speaking and taking leadership positions. A later publication, from 2007, however, states that “the reality is that some groups already permit those on drug replacement to share and lead meetings while others do not.” Since each group is autonomous, Nickels says, “Group conscience will ultimately determine the level of participation of those on drug replacement,” including buprenorphine. Nickels stresses that the group’s official stance is “we’re encouraged to open wide the doors of our meetings to any addict who wishes to join.”

For maintenance patients, this means that most NA meetings may be tricky to negotiate. In some, they will be seen as sober members, working a good program as long as they participate fully and honestly. In others, their recovery literally will not count and they will be banned from speaking. For people who are alcoholics as well as opioid addicts, however, AA’s policies on medications state that “we are not doctors” and that medication prescribed by a knowledgeable physician aware of the patients’ addictions is acceptable when taken as prescribed.

With the ability to integrate people on medication-assisted treatment into at least some 12-step meetings, Hazelden was able to clear a significant hurdle. But Seppala remained concerned about staff resistance, recalling a training when a real old-timer stood up. She herself had been with Hazelden for decades, first as a patient, then working in the kitchen, next as a counselor and finally as a supervisor. She had beaten heroin with 12-step abstinence and made a career out of helping others do so. Seppala was worried.

When Cheryl spoke, however, she took an unexpected stance. While abstinence had worked for her, she said, it had failed miserably for her daughter, J. Seven rehabs—including Hazelden—had not been able to break her addiction to prescription opioids. But on Suboxone, J. had managed for the first time to put together a year of recovery and regain custody of her child. “This melted everyone in the room,” Seppala says, although he knows that not everyone in the organization is totally convinced.

One reason for ongoing concern is the widespread misconception that people on Suboxone or methadone are “high” all the time—just as alcoholics would be always drunk if “maintained” on alcohol. But alcohol and opioids are different drugs, with different pharmacological effects on the brain. With alcohol, while people do develop some tolerance to the impairment in motor control and cognition caused by drinking, this tolerance is not complete and drinking always results in some deficits. By contrast, with opioids, complete tolerance develops not only to the high but also to the associated impairments. If someone takes a steady, regular dose, he or she will be as capable as anyone else of driving, being emotionally open and working productively, as many studies find.

Several private rehabs—including Hazelden itself—met in October to develop a “white paper” to shore up support for abstinence-only.

“I could tell you so many stories of people I treated who go to school, get jobs, even practice medicine,” says O’Brien of his patients on maintenance with methadone or Suboxone.

Why, then, does the myth prevail that maintenance patients are always high? Part of the problem has to do with a feature of maintenance that more often looks like a bug. That is, maintenance treatment tends to retain relapsers at a much higher rate than abstinence-based treatment. People who are actively relapsing aren’t exactly welcome in sober housing or residential rehabs—and they tend not to spend much time at 12-step meetings, either. (Although we have all known people who are actively relapsing who continue coming to AA meetings. Drunk folks at meetings are not an uncommon sight at certain meetings.) While some attend when they are ready to try to get clean again, active users who don’t want to stop have little reason to hang out at meetings. This makes those who are doing well and maintaining recovery visible in rehabs and meetings and those who are slipping and failing far less so.

Maintenance treatment, by contrast, tends to keep relapsers in care. They “use on top” rather than dropping out, which can be helpful because it at least provides some engagement with medical car, it often reduces use when not eliminating it, and it allows the choice to abstain when desired by preventing withdrawal symptoms.

This, however, makes maintenance "look" far worse than abstinence. At any given time, most people in treatment aren’t succeeding with either abstinence or maintenance. But the “maintenance failures” are visible at the clinic, while the abstinence failures are not at the rehab. Moreover, the public support for abstinence, and the stigma attached to maintenance, means that the abstinence successes tend to speak out in the media, while the failures quietly blame themselves.

What that all boils down to is that most of the maintenance patients who are visible will be using on top, which will, of course, produce a high—and that will make maintenance itself appear to be intoxicating. Although if you see someone “high” after stabilization on maintenance drugs, generally either they are not taking their medication correctly or they are using alcohol or other drugs as well. In the popular mind, this is attributed not to relapse but to the nature of the maintenance drug itself.

This difference between what you tend to see and hear about maintenance and what the research actually shows accounts for a large part of why treatment providers have often resisted believing the data, journalists have often collaborated in stigmatizing maintenance, and the public remains largely misinformed.

Hazelden has done the right thing by finally accepting the data—the appropriate response is to study the science and understand why it’s so different from what the public believes, not try to find your own tame researchers to torture the numbers into saying what you wish they said. We’ve heard a lot about the rise of quants and their success in both political campaigns and in predicting the outcome of this election. In addiction, we need to join the reality-based community and accept what the research says as well.

Hazelden has just taken a big step in the right direction. They need to be supported, and their lead followed by other programs that have traditionally avoided medication use. In cancer therapy, we don’t have some hospitals that give all patients chemo regardless of their condition, while other centers swear only by radiation. That would be malpractice. It’s long past time that addiction programs stopped doing the medical equivalent by refusing to use medication when appropriate.

Maia Szalavitz is a columnist at The Fix. She is also a health reporter at Time magazine online, and co-author, with Bruce Perry, of Born for Love: Why Empathy Is Essential—and Endangered (Morrow, 2010), and author of Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids (Riverhead, 2006).

Please read our comment policy. - The Fix
Maia Szalavitz.jpg

Maia Szalavitz is an author and journalist working at the intersection of brain, culture and behavior.  She has reported for Time magazine online, and is the co-author, with Bruce Perry, of Born for Love: Why Empathy Is Essential—and Endangered, and author of Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids. You can find her on Linkedin and  Twitter.