There are really two ways that we could approach the current opiate crisis here in the states: One, we could just blindly throw every resource and support that we have at struggling opiate addicts, hoping that something will take hold and actually help them, or we could get organized and use some sort of system to experiment and hope to learn something from it.
The Chicago Tribune says that “An MVP approach does exactly that by allowing several states to work on different solutions and learn from each other.”
So the idea is that we would organize these experiments in which we might take one group of struggling addicts and put them on MAT, such as Suboxone maintenance therapy. Then we might take another group and refer them only to 12 step programs after inpatient treatment. Then we might take a third group and have them do both MAT as well as 12 step therapy.
We could introduce another variable such as IOP groups that are attended 3 times per week following inpatient treatment. We could have a group that does MAT and lives in long term recovery housing that lasts up to 90 days. We could have a group that sees a therapist weekly after inpatient rehab, both with and without MAT.
So there are a number of different variables and dimensions that we could study and measure in terms of the current opiate crisis.
One of the problems with such a study, however, is that such an experiment tends to disregard the principle of surrender. What does this mean exactly?
It means that there is a very bold line drawn between the struggling opiate addict who is in a state of real surrender versus all of those struggling opiate addicts who are still in denial. Now you might secretly be thinking that some of these solutions that are mentioned above might have the ability to pull someone who is sort of “on the border between denial and surrender” all the way over to successful recovery.
My experience is that this is not the case. We do not have a way to sway an addict into surrender at this point, and sending someone in denial to any kind of treatment services is really just a delay tactic. If they are not done abusing drugs then they are simply not done yet.
Why is this a problem? I think it is a problem because of the way that we have to conduct a study. We first have to get people to participate in the study, and we are going to be grabbing groups of people who are at obviously different points in their spectrum between “blatant denial” and “total surrender.” Remember, even though there is a vast scale between those two points, there is a very definitive line at which a person will actually “make it” in recovery. Anything falling below that line results in future relapse, regardless of how many treatment services you throw at them.
This is a bit like the person who goes to several different recovery programs while they are in denial, and eventually they go to a certain recovery program and suddenly everything clicks and they remain clean and sober. They believe that the last recovery program that they attended is lined in magic, and that it is the one true solution in the world, and that all of those other recovery programs that they failed at previously must be completely bogus and worthless.
Of course this is wrong–the person went to several rehab programs, and then they finally surrendered within themselves and went to the final program, which worked out for them. It is not because it was a magical solution, it was because they finally surrendered. They erroneously give all of the credit to the last program they attended, not realizing that any of the solutions would have worked for them because they had finally hit bottom and truly surrendered. They were finally ready to change. It’s the surrender, not the program!
And I think that any study that attempts to find the perfect mix of treatment services is going to suffer from this same kind of short sighted thinking. They are going to grab up large groups of study participants and run them through various treatment services, and all they are really going to be measuring is the select population that had fully surrendered, versus those who were still in denial.
“But wait” you say, “this sounds like you are suggesting that there is no difference in the effectiveness of various treatments, and that they are all the same.”
Yeah, I kind of am suggesting that. The truth is that the level of surrender matters so much more than any specific programs or services that you might believe are “the ultimate answer.”
Another bias that can short change this kind of experimentation is that of the self selecting bias when it comes to something like MAT.
It is difficult to force a struggling addict to try MAT (medication assisted treatment) just for the sake of your study.
Therefore, what is going to happen when they attempt to study these services is that you are going to get people in rehab who heard about MAT and decided “that sounds like it might really help me.”
This is a self selecting group based on the allure of a “magic pill that cures addiction.”
What do I mean by this? Just that, if you take a bunch of struggling opiate addicts, and you send them all to rehab, a certain percentage of those people are going to hear about Suboxone maintenance and they are going to seek it out for themselves. They are doing this because it sounds like a magic pill that will remove all of their cravings. And the group that seeks this out aggressively is not going to have as high a success rate as if you randomly selected people to try MAT.
Because they are seeking the “easier, softer way.” I am not saying that MAT doesn’t work, I am only saying that the people who seek it out aggressively are not truly in a state of full surrender (typically). I know this because I have watched it unfold with thousands of clients in a real treatment environment. Those who aggressively seek out MAT are usually not quite ready yet in terms of the denial-surrender scale.
But my hope is that these states can experiment with different services and somehow get past these limitations that I have discussed here. My hope is that they can learn some key insights and that they can form better treatment plans.