Further Reflections on Addiction Treatment Medications

The iconic image that pervades pharmacotherapy of opioid addiction is a shadowed face drinking a pale liquid from a plastic medicine cup. The image of a faceless, voiceless person is apt as the historical stigma attached to the use of medications in the treatment of opioid use disorder is so great that few have braved stepping into the light to share their lived experience of medication-assisted recovery. Poised on opposing sides of this image are medication haters and medication advocates, each offering radically different views on the potential value, risks, and limitations of medication support in recovery from opioid addiction. One finds on both sides people who have negative and positive personal and professional experiences in the use of these medications, people grinding innumerable ideological axes, and people whose organizational destinies, personal careers, and financial interests are vested in the outcome of decisions to use or not use medication as an aid to addiction recovery.

For years, I have tried to forge bridges of communication across the polarized, vitriolic debates surrounding the use of medications in the treatment of addiction. I have illuminated the history and current status of medications in the treatment of addiction and reviewed the policies toward medication of major recovery mutual aid societies. I have championed the value of key medications and the legitimacy of medication-assisted recovery. And I have called on medication-centered addiction treatment providers to dramatically expand the scope of their recovery support menus and elevate the quality of their service practices. This latest missive seeks ultimately to lessen the challenges and confusion faced by affected individuals and families as they sort the pro-medication and anti-medication polemics within public, professional, and social media.

I have just posted a paper to help recovery advocates understand some of the complexities and limitations involved in the use of medications and to better understand the positions of some who reject the use of medications as a panacea for opioid and alcohol use disorders. The hope is that recovery advocates can help educate affected individuals and families on the limitations of medications at the same time they assert their potential benefits. There is limited long-term value in replacing a mindless ant-medication bias with an equally mindless pro-medication bias. The challenge for recovery advocates is to forge a source of reliable information between the extremes of “Never” among the rabid medication haters and “Always and Forever” among the most passionate medication advocates. In our efforts to promote the legitimacy of multiple pathways of recovery—including medication-supported recovery, we need far more nuanced discussions of the potential value, the limitations, and the possible contraindications of medications across the stages of recovery.

I invite and encourage all recovery advocates and recovery support specialists to review this latest paper by clicking HERE.

Medications are best viewed as an integral component of the recovery support menu rather than being THE menu, and their value will depend as much on the quality of the milieus in which they are delivered as any innate healing properties they may possess. The “Just get them [medications] out there: Stop the dying!” mantra is understandable in the face of the onslaught of drug overdose deaths but it is not an effective foundation for drug policy. A similar mantra promoted by the pharmaceutical industry–“Just get them [medications] out there: Stop the pain!”–helped create the current crisis. Effective drug policies and personal recovery management strategies must include an understanding of the capabilities AND the limitations of pharmacotherapy in the treatment of addiction and co-occurring disorders. A synergy of influences spawned the current crisis and it will require a synergy of remedies to end it at both personal and public health levels. When communities approach us as experts and ask, “What is the one thing we can do?” our response should be “Don’t do just one thing and rigorously evaluate and elevate the quality of everything you do.”      

People seeking recovery from opioid use disorders and their families are in desperate need of science-grounded, experience-informed, and balanced information on treatment and recovery support options—information free from the taint of ideological, institutional, or financial self-interest. In an ideal world, recovery advocates would be a trustworthy source of such information.

Key earlier publications of related interest include the following:

McLellan, A. T., & White, W. L. (2012). Opioid maintenance and Recovery-Oriented Systems of Care: It is time to integrate. Invited commentary on Recovery-oriented drug treatment: An interim report by Professor John Strang, Chair of the Expert Group. (DrugLink, July/August, pp. 12-12). London, England: The National Treatment Agency.

White, W. (2012). Medication-assisted recovery from opioid addiction: Historical and contemporary perspectives, Journal of Addictive Diseases, 31(3), 199-206.

White, W. L. (2011). Narcotics Anonymous and the pharmacotherapeutic treatment of opioid addiction. Chicago, IL: Great Lakes Addiction Technology Transfer Center and Philadelphia Department of Behavioral Health and Intellectual disability Services.

White, W. L. (2007). Addiction recovery:  Its definition and conceptual boundaries. Journal of Substance Abuse Treatment, 33(3), 229-241. doi: 10.1016/j.jsat.2007.04.015

White, W. L., & Coon, B. F. (2003). Methadone and the anti-medication bias in addiction treatment. Counselor, 4(5), 58-63.

White, W., Parrino, M., & Ginter, W. (2011). A dialogue on the psychopharmacology in behavioral healthcare: The acceptance of medication-assisted treatment in addictions. Commissioned briefing paper for SAMHSA’s A Dialogue on Psychopharmacology in Behavioral Healthcare meeting, October 11-12, 2011. Posted at www.williamwhitepapers.com

White, W. L., & Torres, L. (2010). Recovery-oriented Methadone Maintenance. Chicago, IL: Great Lakes Addiction Technology Transfer Center, Philadelphia Department of Behavioral Health and Mental Retardation Services, and Northeast Addiction Technology Transfer Center.