*Strategically* disruptive treatment?

December 24, 2022
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I recently read this article envisioning minimally disruptive treatment for opioid use disorder.

People who use drugs have long called for reforms to make opioid use disorder (OUD) care more patient-centered and less disruptive. Their calls align with broader healthcare transformation efforts, particularly to create “minimally disruptive” systems. Minimally disruptive medicine (MDM) is a “patient-centered and context-sensitive approach” focused on supporting patients’ life goals and health “while imposing the smallest possible treatment burden on patients’ lives.

Englander, H., Gregg, J. & Levander, X.A. Envisioning Minimally Disruptive Opioid Use Disorder Care. J GEN INTERN MED (2022). https://doi.org/10.1007/s11606-022-07939-x

My first reaction was to reflect on the reality that, over the years, most of my clients needed very significant disruption in their lives to achieve recovery — disruption in their social networks, cognitive models, emotional regulation, sleep, diet, family relationships, etc. Most of that necessary disruption occurred in the context of contact with addiction professionals and other people seeking recovery in treatment and mutual aid settings. That disruption is an essential part of the journey to becoming “better than well.”

I have that reaction as someone who has been a leader in efforts to implement a low-threshold prescribing model in an emergency department. However, I see that low-threshold practices as something akin to first aid and emergency care, rather than an effective treatment for a chronic illness. My wish is that those interventions prevent death, temporarily stabilize patients, and serve as an opportunity to engage the patient in a more comprehensive model of care.

I also recently came across the campaign Program, not a pill. The campaign appears to be a response to growing pressure in recent years to frame medication as an effective treatment on its own.

The majority of people with OUD have more than just OUD, and the medications don’t work for those other issues—common co-occurring conditions include other substance use disorders, mental health problems, difficulty functioning or working in society, social problems, etc. Comprehensive treatment programs can individualize care for each patient based on their own strengths, weaknesses, conditions and circumstances.

Not all 11 symptoms of OUD always respond well to medication treatment, so multiple interventions are necessary for the patient to stop use. That is, even if the physiologic symptoms are rather well addressed with medication, many patients continue to struggle.

Program, not a pill

Also, just this week, the Wall Street Journal has been reporting on the shortcomings of multiple digital behavioral health providers. Many of these services started with a vision of minimally disruptive care. Their reporting raises questions about whose needs are met with that model — the patient, or the treatment program?

These reactions, in no way, invalidate the Englander article’s critique of maximally disruptive practices. There’s no question that some disruptive practices are rooted in or propped up by stigma. The pandemic has provided a helpful opportunity to step back and examine some of those practices.

Yet, it also feels, to me, like we’re approaching an inflection point in the opioid crisis, where many families, policy-makers, patients, and providers are recognizing that we cannot prescribe our way out of the opioid crisis. This seems particularly important at this moment, as opioid settlement dollars flow into states and localities and, often, the easiest lift is to invest it in medications. (Despite the irony of returning restitution from pharmaceutical companies to pharmaceutical companies.)

So… where do all of these mental meanderings lead me? To be sure, some people will thrive with minimally disruptive models, but many will suffer and die without much more disruptive models. There’s a lot of variation in people’s pathways into addiction, their experience in addiction, and their pathway to recovery.

I suppose, rather than minimally disruptive or maximally disruptive, we ought to be focused on strategically disruptive models of care that do not rely on coercion and instead provide visible, realistic, and comprehensive pathways to recovery that will attract people voluntarily. It sounds easy, but this model was envisioned more than 20 years ago and, despite countless proclamations to the contrary, it’s never been realized at any large scale. It also runs against the zeitgeist (see here, here, and here), which frames patient-centered as organized around the patient’s short-term preferences that are often explored and understood in the context of systems and choices that offer no visible and realistic path to flourishing.

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