Many [blank] treatment programs don’t offer [blank], at a deadly cost

This article, Many Residential Addiction Tx Centers Don’t Offer MAT, at a Deadly Cost, has some serious flaws but it addresses an important and common gap in systems of care.

What it gets wrong

The flaws relate to it being a mish mash of criticism of non-agonist treatments.

First, the article seems to be muddying distinctions between residential treatment and recovery housing. The patient discussed seemed to be in a residential program that allowed agonists, but discontinued because there were no recovery homes that allowed opioid agonists.

Second, it represents residential treatment as something akin to a Pentecostal cult. Spirituality is commonly found in treatment, but requiring begging for forgiveness and administratively discharging people for atheism are far outside accepted practice.

Third, the author says 12 step approaches are not backed by research and strangely links to the flawed and misunderstood 2008 Cochrane review rather than the new 2020 Cochrane review, which concluded:

There is high quality evidence that manualized AA/TSF interventions are more effective than other established treatments, such as CBT, for increasing abstinence. Non-manualized AA/TSF may perform as well as these other established treatments. AA/TSF interventions, both manualized and non-manualized, may be at least as effective as other treatments for other alcohol-related outcomes. AA/TSF probably produces substantial health care cost savings among people with alcohol use disorder.

Alcoholics Anonymous and other 12-step programs for alcohol use disorder (Review)

Fourth, it raises concerns about health professional recovery programs without mentioning that they happen to have really good outcomes.

What it gets right

The article explores some of the barriers to integration of agonists into residential, housing, and health professional monitoring programs. The article closes with this:

“People with substance use disorder need access to this medication, maybe for short-term, maybe for long-term, or maybe for the rest of their lives,” Hornak said. “They should not be discriminated against.”

Let’s set aside my belief that articles like this often overstate the effectiveness of agonist treatments.

The issue that this article gets right is that these patients deserve better access to the full range of recovery support services.

Access to residential that allows agonists is limited and probably non-existent in a lot of regions.

Worse, access to recovery housing is also too limited for patients on agonists. This issue of access to housing was central to the tragedy the article opens with.

What it overlooks

The article overlooks a couple of important things.

First, there are good reasons for wanting an agonist-free treatment/recovery environment.

Acknowledging that agonist-free treatment/recovery environments are important does should not be construed as suggesting that agonist-inclusive environments are not important.

Second, the article doesn’t seem to pause to contemplate who is responsible for these patients and meeting their needs. The insertion of discrimination places moral responsibility on non-agonist programs. However, given my first point, maybe we should question that assumption.

It is very frustrating that it can be so difficult to find programs that meet the needs of these patients, and it’s natural to direct that frustration at programs that exclude them. Indeed, any program that claims to care deeply about people with addiction is obliged to make meaningful efforts to meet the needs of these patients, particularly as their numbers grow and the overdose crisis persists.

All this is true, AND that headline could just have easily read “Many MAT Programs Don’t Offer Recovery Housing, at a Deadly Cost.“

It’s worth stopping and asking where existing recovery homes came from. In my region, many of these homes were started by recovering people who wanted to help people along the pathway that made their recovery possible.

The other recovery home operators are treatment programs. At Dawn Farm (I no longer work there), we opened our first house in 1998 because we knew many of the people we saw in our social detox program didn’t need residential treatment but also needed more support than outpatient treatment could offer. We soon realized that this service could shorten residential stays, improve outcomes, and extend the duration of recovery support.

We didn’t want to get into the housing business. We saw it as outside of our scope of services and it demanded skills and knowledge we didn’t possess at the time. We thought someone else should do it, like a housing program, but it was also clear that no one else was going to develop a program around our client’s specific needs. Our model didn’t make money and was a lot of work. (Though it did cover its costs.) We did it in pursuit of our mission to help people with addiction achieve long term recovery.

It would be a very good thing to see MAT providers (and advocates) similarly work toward developing a broader continuum of recovery support services to meet the needs of their patients. (I write this as the director of a program that provides MAT and needs to do better at developing systems of community-based long-term recovery support.)