Commentary on – Seizing the Moment to Improve Addiction Treatment

In this volume, Dr. Robert DuPont, FASAM, has written a typically eloquent and compelling follow-up to an earlier article(1) calling for adoption of a 5-year abstinence standard in the evaluation of addiction treatment. Bob asked me to review and comment on his first draft of this follow-up article, and after reviewing I wrote him telling him I could not completely agree with his proposal. Instead of angrily dismissing my views, Bob asked ASAM to invite me to provide my critical comments in this companion article. Those who know and work with Bob DuPont will not be a bit surprised at this – he is far more interested in progress and improvement than in simply promoting his own ideas. So with that as context I offer the following comments on this very provocative and important idea for our field.

I do agree with many core elements of the arguments put forth in this succinct and eloquent proposal. An operational definition of recovery is critical if the term is to have relevance outside the circle (a large circle) of those who are already in recovery. There is also need for sensible, clinically meaningful and broadly understandable treatment standards for the addiction field, especially as more insurance financing begins to attract providers with neither the ability nor the ethics to provide quality care. Moreover, I think it is quite right to urge ASAM to take on the setting and promotion of these standards as part of their leadership and liaison efforts with mainstream medicine and healthcare. Finally, I agree that one key indicator of recovery is abstinence (from all illicit and non-prescribed substances); while it does not fully capture the full concept (see Betty Ford Consensus paper)(2) it is central to that concept and a good general marker of broader improvements in patient health and function.

My concern is with the setting of five years of continuous abstinence as the gold standard. This is certainly an achievable goal as has been shown by the DuPont and colleagues studies of recovering physicians(3, 4); the Moos and colleagues studies of veterans(5, 6), and the general recovery studies of Kaskutas(7). It could also have very important health, life and disability insurance implications for those in recovery. And, like any good “gold standard”, it will be a stretch for our field. More than just a measurable target, the 5-year recovery standard has real, gut-level significance – I truly hope every person with addiction gets the care needed for them to met that standard.

But I have two problems:

1. Is 5-years long enough? The cancer field has correctly popularized five years of remission as a term indicating “survival.” From empirical research we know that after about five years of remission, a “recovering” cancer patient has about the same chances of re-contracting the illness as the public at large – meaning they no longer have elevated odds of getting cancer.

   Can it be said that at five years of abstinence individuals recovering from addiction have the same chance of contracting a substance use disorder as the public at large? Even if the answer is empirically “yes,” it will continue to depend upon the recovering person’s ability and will to remain abstinent. Can it be said that five years can effectively cement those behavioral changes in place? Even more provocatively, is it conceivable that a five year period of continuous abstinence might reverse brain and gene expression changes leading to loss of control over substances and enable “normal” control of substance use? Any or all of these are possible, but not yet substantiated.

    

2. Don’t shorter periods of recovery also matter? Doesn’t it count that an individual is able to attain and remain abstinent for one year, ninety days or even one week as part of some form of outpatient addiction treatment? I am focusing on outpatient care because recovery is most severely tested in outpatient or office-based settings of care. Also, I am including in outpatient treatment not simply so-called “drug-free” treatments but all medication maintenance forms (methadone, naltrexone, buprenorphine) as well. In the rest of medicine, key markers of the disease (e.g. HgA1C, BP, etc.) are measured from the very beginning and throughout all stages of treatment, and monitoring is considered as a continuing indication of “disease control.“
   

   Wouldn’t it be better for our field to begin to measure and record abstinence (any number of valid ways) from the beginning of outpatient care, and for months and years following termination of formal care through remote monitoring (see 8)? While five years of abstinence is certainly laudable, the sad truth is that as a field we currently do not know what proportion of individuals who begin any outpatient treatment actually attain abstinence – or for how long – even during clinical management.

What about 1-Year Abstinence? I think the proposed standard of five years of continuous abstinence is simultaneously too long (we do not currently know how many people are abstinent for one week during treatment) – and also too short (we do not yet know at what point relapse risk approximates population rates). But like Bob DuPont, I too want to help improve the quality of care, and with it the level of understanding and confidence in addiction treatment by the public and by mainstream healthcare.

So I am suggesting a one-year continuous abstinence standard as an achievable but currently aspirational goal for our field. Like Dr. DuPont I think abstinence should be operationally defined to include all illicit or non-prescribed drugs. Put differently, I am in the camp that believes recovery includes patients who achieve abstinence through properly prescribed and taken medications. Further, I am suggesting that the period of abstinence should be measured from the beginning of any type of outpatient treatment, and for at least one year thereafter – regardless of whether the individual is still receiving care. Again, I think this is entirely consistent with the methods used in the rest of healthcare.

I am aware that this suggestion is as arbitrary and has all the same problems as the five-year standard – but I think it has some advantages:

1. Several treatment evaluation studies have shown that the great majority of relapses occur within the first year following treatment, most within the first six months. Thus, confirming one year of abstinence will address this critical period.
2. Not many people achieve it now – so, like any good aspirational goal it will be a stretch for the treatment field.
3. It is within the realm of contemporary insurance coverage and thus relevant to important financing and coverage policy issues that will shape our field.

In conclusion, I want to re-emphasize that both Dr. DuPont and I feel now is the time for our field to come to consensus on standards of effectiveness or recovery measurement. We also agree that ASAM is the organization to spearhead this effort because this is clearly a medical/healthcare issue, because ASAM is our field’s expert medical association, and particularly because ASAM has already united our field through publication and refinement of The ASAM Criteria, Treatment Criteria for Addictive, Substance-Related and Co-Occurring Conditions. That effort has been a signal achievement in getting our disparate field to speak in one clear voice about a complex concept. A similar effort to bring about “ASAM Outcome Criteria” is every bit as important for payers and consumers but also to our field to drive innovation and competition. I hope ASAM will use the occasion of Dr. DuPont’s letter to again lead our field toward meaningful, measurable treatment outcome standards.

REFERENCES

1. DuPont, R. L., Compton, W. M. & McLellan, A. T. (2015). Five-year recovery: A new standard for assessing effectiveness of substance use disorder treatment. Journal of Substance Abuse Treatment, 58, 1-5.
2. The Betty Ford Institute Consensus Panel. (2007). What is recovery? A working definition from the Betty Ford Institute. Journal of substance abuse treatment, 33(3), 221-228.
3. DuPont, R. L., & Skipper, G. E. (2012). Six lessons from state physician health programs to promote long-term recovery. Journal of Psychoactive Drugs, 44(1), 72-78.
4. McLellan, A.T., Skipper, G.S., Campbell, M., DuPont, R.L. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. British Medical Journal 337:a2038, 2008.
5. Moos, R. H., & Moos, B. S. (2005). Paths of entry into Alcoholics Anonymous: Consequences for participation and remission. Alcoholism: Clinical and Experimental Research, 29(10), 1858-1868.
6. Finney, J. W., Moos, R. H., & Timko, C. (1999). The course of treated and untreated substance use disorders: Remission and resolution, relapse and mortality. Addictions: A comprehensive guidebook, 30-49.
7. Kaskutas, L. A. (2009). Alcoholics Anonymous effectiveness: Faith meets science. Journal of addictive diseases, 28(2), 145-157.
8. McLellan, A. T., McKay, J. R., Forman, R., Cacciola, J., & Kemp, J. (2005). Reconsidering the evaluation of addiction treatment: from retrospective follow‐up to concurrent recovery monitoring. Addiction, 100(4), 447-458.

A. Thomas McLellan, Ph.D., Chair of the Board, is co-founder of the Treatment Research Institute (TRI) and an experienced substance abuse researcher. From 2009 to 2010, he was Science Advisor and Deputy Director of the White House Office of National Drug Control Policy (ONDCP), a Congressionally confirmed Presidential appointment to help shape the nation’s public policy approach to illicit drug use. At ONDCP, McLellan worked on a broad range of drug issues, including formulation and implementation of the President’s National Drug Control Strategy and promotion of drug treatment through the broader revamping of the national health care system. Dr. McLellan has more than 35 years of experience in addiction treatment research. In 1992, he co-founded and led (until his ONDCP appointment) TRI to transform the way research is employed in the treatment of and policy making around substance use and abuse. In his career he has published over 400 articles and chapters on addiction research.