In my experience, abstinence is not an effective or attractive option for those seeking treatment for opioid dependence. Methadone has been used for decades with a high rate of success. Most drug-dependent individuals relapse within a year in abstinence-based treatment programs, however those being treated with methadone who have achieved abstinence from other drugs of abuse as well are highly successful and have returned to mainstream life, in our clinic. It would be unethical to deny opioid substitution therapy to a person seeking treatment for opioid dependence.

The much of the literature was about heroin dependent long term addicts and clearly the two options were long term residential treatment of at least 6 months or opioid maintenance. Short term detox treatments in these populations were clearly ineffective. Now days we have a great deal of prescription opioid dependence , some with patients with chronic pain, some with anxiety , and some with clearly addiction as the primary disorder. The data is not as clear in these populations because the duration of dependence varies, but the longer the duration, the more it seems that they are like the old heroin dependent patients. Injectable naltrexone has now come on and shows some promise and is FDA approved for this. A new application of a long used approach is aversion therapy for the opioid use. It still needs to be tested in long term outcomes, but aversion for alcohol and cocaine and smoking dependencies has been very effective in certain populations. Clearly, any abstinence program has to focus on retraining the patient's stress management, anxiety response system and PTSD , and often will require other medications to address these issues. Untreated dual diagnosis also needs to be addressed and may have played a role in impacting the heroin results as well. There is no conflict between 12 step spiritual growth and opioid maintenance or the use of other modalities. Patients with Chronic pain need to be divided into those with ongoing mechanical injury, those with hx of opioid dependence independent of their injury, and those with high anxiety/PTSD prior to or as a result of their injury. The first group may or not be addicted but function better with their opioid maintenance. The second group continue to seek opioids even when the injury resolves and are more like the original opioid dependent patient. The latter includes patients with Fibromyalgia and migraine headaches. The latter group do better with a multidisciplinary program.

The risk of relapse in opioid dependence is special in that a person who had a tolerance and lost it during treatment, and relapses at the same dose level that they used to use, often dies due to loss of tolerance.

The above information should be part of informed consent which allows the patient to choose treatment options for him/herself. Because the risk of relapse to opioid dependence can be fatal this needs to also be included in any informed consent.

Patrick, Thanks for the measured clarity.