This is a question that’s certainly generating a lot of discussion in our industry these days. In fact, a recent article in Addiction Professional took square aim at the issue by implying that “it’s unethical not to use medications.” Well, it’s just not that simple whereby anyone should be making a blanket statement to that effect.

We’ve all seen, read or heard about successful addiction treatment, ranging from abstinence-only to medication-friendly and somewhere in between where medication is used only in the facility. It’s worth repeating here: Addiction treatment is not a simple process. So, perhaps, it’s worth delving a little deeper into some of the complexities that keep us from taking a one-size-fits-all, medicate-everyone approach to addiction treatment.

A good place to start is co-occurring disorders. There are varying opinions in our field about the existence and treatment of co-occurring disorders. Does a person who has both an alcohol or drug problem and an emotional/psychiatric problem warrant a dual diagnosis? At times, the symptoms of both problems can overlap and even mask each other, making diagnosis and treatment more difficult. There is discrepancy over diagnosis. Is it truly a dual diagnosis? And which is primary in the diagnosis—the substance abuse or the psychiatric disorder? Further, how is it treated?

So, taking this into consideration, are centers that avoid drug treatments for addiction really shunning science and ethics?

There are reasons to be skeptical of current research in the addiction/psychiatric arena. There have been increasing allegations of “sham” science funded by pharmaceutical companies with researchers on payrolls of drug companies.  Hopefully this is a true minority, but these studies tend to have small numbers and short follow-up. In addition, there is inconsistency in reproducing findings.  With billions of dollars at stake, there needs to be a true clinical “real-life” verification when it comes to these new drugs. Abstinence-based treatment has a long, successful record in treating addictions and there needs to be ongoing support for this approach regardless of developments in the medication-assisted arena.

Medical practitioners have tried to adhere to their oath of “First, Do No Harm.” There is an ongoing debate between medication-assisted and abstinence-oriented treatment philosophies as to what constitutes harm. Successful treatment of addiction has traditionally been an all-or-nothing undertaking, involving complete abstinence rather than a regimen of moderation. For many, that definition includes abstinence even from drugs that may help fight cravings.

This trend toward “harm reduction” follows European moves in a similar direction.  In fact, the United States is the last country advocating for abstinence in addiction. This is a scary trend and this path should be trod carefully because once there, there is no going back. So the total abandonment of a philosophy that has led to millions of recovered lives deserves careful scrutiny. These new medicines are not magic bullets. They may have a place but we do not yet know enough for them to be the only option. The experience of a true abstinence-based program is beyond valuable, as there will always be a need for someone to start from a “clean slate. Although many providers have recently become open to new options, the majority of American addiction treatment continues to use the abstinence model.

Since many symptoms of substance abuse mimic other psychiatric conditions, the person must go through a withdrawal from alcohol and/or drugs before the physician can accurately assess whether there is also an underlying psychiatric problem. Making a dual diagnosis in substance abusers is difficult as drug abuse itself often induces psychiatric symptoms, thus making it necessary to differentiate between substance-induced and pre-existing mental illness. More often than not, psychiatric disorders among drug or alcohol abusers disappear with prolonged abstinence.

While everyone is screaming for evidence-based practice, what we really need is practice-based evidence. The data and rationale for what ‘should’ work are far different from what happens in real life. What we hear from patients coming into the program and what we see happening in treatment centers like Willingway shows us what is working.