By John Sorboro, MD, ABPN, Chief Medical Officer, Behavioral Health, for Health Services Advisory Group
Traditional psychosocial treatments for addictions—such as 12-step programs—can be successful tools, but unfortunately, they often fail. The failure is in part because 12-step therapy relies on an appeal to a “higher power,” despite the fact that many patients lack religious or spiritual beliefs and; therefore, struggle with this concept. Another downfall to the abstinence-based approach is that it usually frowns upon the use of medically assisted therapies for the treatment of Opioid Use Disorder (such as Methadone or Buprenorphine), even though these treatments often have good results.
The role of traditional detox programs and in-patient rehab is being questioned, and with good reason.1 It would be nice if we could send our loved ones away for a few weeks and have them come back healed, but this is usually not what occurs. Failure is common, and there is little evidence that the benefits justify the tremendous cost. Instead, there is evidence that such an approach in the treatment of Opioid Use Disorder may increase the risk of fatal overdose.2 When former addicts are discharged from rehab (or jail) and relapse on opioids, their tolerance is reduced. If they take the amount of opioids they used to take, that amount may now be fatal. Often, the far better treatment is medically assisted therapy with medication, and if possible, a very gradual taper over a long period of time.
Proper medication can be lifesaving when appropriate, but after this begins, I suggest working with patients on five key areas of recovery and making real change in each.
Work: Everyone needs a purpose and a reason to get up in the morning. In the early stages of recovery when people struggle the most with cravings, work is integral to their recovery and keeps their mind away from the things that trigger their addiction. Also, most people who are starting recovery need to dig themselves out of a financial hole, and work serves a practical purpose.
Relationships: All relationships must support sobriety. No friends who use. No unstable relationships that trigger use. And no special exceptions for family members!
Self-care: Addiction takes a terrible toll on the body. In recovery, patients must start eating better and exercising. For most patients, it’s been years since they’ve seen a doctor or dentist.
Pursuit of pleasure: Play is as important as work. Patients must pursue pleasure through healthy hobbies and interests. This is critical to self-development.
Philosophy: We all must have a set of guiding principles, particularly when life gets difficult. For instance, I find Stoic philosophy indispensable. Others depend on what they learn through cognitive-behavioral therapy, or maybe they combine components of several philosophies. The point is to positively change the way you think and act.
None of these five keys moralize addiction or substances. Programs and associated philosophies that moralize addiction and substances can be harmful and may make patients struggle with undue shame. Indeed, there are no “good” or “bad” substances. Aspirin can be both a cure and a poison. This is the case with opioids as well. Such substances should be used to improve our lives while doing as little harm to our bodies as possible.
This is the goal with medically assisted therapies such as Buprenorphine and Methadone. When used effectively, they can relieve the paralyzing sickness of acute opioid withdrawal, as well as chronic cravings, fatigue, depression, and body aches.3 Medication can, and often does, help individuals with Opioid Use Disorder, but patients also need an effective state of mind and a desire for a new life. They must show a willingness to work and accept responsibility. A positive state of mind, proper medication treatment, and the five keys may give patients the best possible chance to succeed.
John Sorboro, MD, ABPN, is chief medical officer, behavioral health, for Health Services Advisory Group; a diplomat of the American Society of Addiction Medicine; and medical director of the Restorative Health and Recovery Clinic.
This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. AZ-11SOW-C.3.6-03292019-01.
- Harmon K. Does Rehab Work as a Treatment for Alcoholism and Other Addictions? Scientific American. July 2011. Available at: https://www.scientificamerican.com/article/does-rehab-work/. Accessed on: April 2, 2019.
- Strang J., et all. Loss of Tolerance and Overdose Mortality After Inpatient Opiate Detoxification: Follow-up Study. BMJ. May 2003. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC153851/. Accessed on: April 2, 2019.
- Gavin K. How Primary Care Doctors Can Help Patients Beat Opioid Addiction. University of Michigan Medicine. Oct. 2017. Available at: https://labblog.uofmhealth.org/rounds/how-primary-care-doctors-can-help-patients-beat-opioid-addiction. Accessed on: April 3, 2019