"I agree with so much of your analysis. Why are you classifying Medication Assisted Treatment as harm reduction though? When it is THE scientifically proven treatment for opioid use disorder? Abstinence is not recommended for individuals with opioid use disorder, yet your post suggests that is the real recovery goal. A full and beautiful life in recovery is possible with opioid replacement therapy – it's not a "limbo state" when done correctly. What a dangerous message."
THE scientific evidence for Medication-Assisted Treatment (MAT) is that it lowers overdose risk and reduces opiate use. This is very important and a critical first step for those abusing opioids. I maintain, though, that there is more to recovery than just this. This is why the clinical directors of MAT programs I have talked to call it harm reduction.
For some, MAT will be the springboard to that beautiful life. It will get them back to work, to show up for their families, and will keep them out of jail. Some will stay on MAT a long time, maybe forever. Hopefully, they will find some counseling and relational work, some skill-building and community support to make that life even more beautiful and balanced.
For others, MAT will reduce the harm and danger of opiate use but will not address the full nature of addiction in their lives. I asked a clinician at a methadone clinic recently how she would characterize the patients at her clinic. She told me 20% are doing very well (by this, she meant making important changes to their lives), 20% are doing very badly (not stable on the medication and still dabbling or using opiates, using other drugs) and the remainder (60%) are in limbo, mostly not using opiates, dabbling in other drugs, but resistant to counseling or other aides that would improve the quality of their lives.
A look at the findings against abstinence (by abstinence I mean no opiate medication substitute) goes something like this: let's put these people on MAT with counseling and let's put these other people just on counseling….. who does better? Those on MAT. Therefore, abstinence is not recommended. This is simply insufficient. Until there is a study that looks at MAT with counseling, compared to comprehensive substance abuse treatment (psycho, social, medical, physical and mental health, housing and employment) – the latter services lasting as long as the MAT dosing – I consider that we simply do not have grounds for comparing the validity/success of MAT with an abstinence-based approach.
There are two arguments against abstinence, the first is the kind of study I just mentioned. The second is the poor outcomes of people who come off of MAT. People relapse when they stop MAT. It can be physically and emotionally arduous to withdraw from methadone or buprenorphine. Without proper supports—and I mean things like a leave of absence from work if needed for a couple weeks, a safe place to sleep (or not sleep since insomnia is common), food, emotional support—you relapse. There are no two ways about it. If you’re out there, isolated and sick, your head will convince you to get high, it’s just too easy a solution.
The majority of people who leave MAT do so against medical advice, meaning they were not ready or supported sufficiently to try living without MAT; they were not carefully titrated off of MAT. They just stopped showing up to their appointments. Many I am sure were headed for a relapse. They didn’t have the kind of recovery supports in place that would be a deterrent and hold them in safety.
Again, outcomes of people leaving MAT are not sufficient evidence that alternatives to MAT don’t work.
My worry is that if we keep putting all our eggs in the MAT basket, funding for these other modalities will become harder and harder to come by, with or without MAT on board, and that is a dangerous message.