Pharmacotherapies as standalone treatments for addictions: why lessening won't work.

Abstract

The debate about whether or not there is a need for psychosocial treatments to accompany pharmacotherapies for opioidmisuse has crossed the ‘pond’with little attention to treating the ‘whole’ person. Indeed, the authors, Day & Mitcheson, recognize that opiate substitution therapy (OST) research may not pay much attention to outcomes associated with psychosocial intervention effects [1]. Conforming to that recognition, the underlying targets of psychosocial interventions must be established explicitly and articulated clearly to appreciate the role of nonpharmacotherapy interventions in the care of people with opioid use disorders. Addiction treatment providers have long been tasked with treating the ‘whole’ person. If we are to meet the needs of the whole patient, an extensive approach to service provision is required to address much more than the drug misuse problem. Thus, in the words of the US National Institute on Drug Abuse [2], ‘the best programs provide a combination of therapies and other services to meet the needs of the individual patient’ (p. 10). Psychosocial interventions and services designed to address more than substance use need to be included in OST research, and outcomes should be assessed with regard to behavioral and life-style changes, rather than simply focusing upon trying to demonstrate that pharmacotherapy by itself is a complete treatment for opioid use disorders. Day & Mitcheson admit the need to adjust care, acknowledge that one size does not fit all and indicate that intervention intensity should be titrated to the needs of the individual. Their notion of applying psychosocial interventions at varying levels is somewhat akin to precision medicine described by the National Institutes of Health as ‘an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle for each person’ [3]. While we are not yet there with regard to genetics and individual treatment choices, addiction treatment should take into account these other variabilities in individual differences when selecting treatments and intensity of care. For far too long, our field has concentrated onmatching ‘patients to treatments’. Although differences may appear to be slight, matching ‘treatments to patients’ is much more precise and obligates us to begin tailoring treatments as suggested by Day & Mitcheson. Rhetoric is often powerful, and can divert the best of intentions concerning what is best for our patients. For example, focusing on the selection of treatments and their intensity and personalizing it for individual patients—adapting regimens based on therapeutic responses—seems more logical than fitting patients into a treatment box that has empirical evidence based on group effects. Ideally, treatment outcomes for all individuals in empirical studies would follow a positive linear trend showing improvements over baseline; in reality, however, some changes are negative and perhaps nonlinear. Thus, not everyone in a positive outcome study shows improvement, and this should invite inquiry into how best to meet individual needs. Much progress has been made in the United States in recognizing drug addiction as a chronic health condition rather than as a social problem. It has been compared to other chronic illnesses, such as diabetes, hypertension and asthma [4], that require medication and more than pharmacotherapies to fully treat and achieve optimal outcomes. That achievement involves changing behaviors and life-styles which can be facilitated through targeted psychosocial interventions. The available evidence base for blending a psychosocial intervention with OST suggests a Hobson-like choice: take it or leave it. This dilemma should not exist in a health-care environment that recognizes addiction as a chronic illness and acknowledges the contributions of biological, psychosocial, behavioral and environmental factors in determining health. Asserting the role of the whole person with regard to addiction treatment may help to lend further support for blending psychosocial interventions with OST.

DOI: 10.1111/add.13707

Cite this paper

@article{Flynn2017PharmacotherapiesAS, title={Pharmacotherapies as standalone treatments for addictions: why lessening won't work.}, author={Patrick M. Flynn}, journal={Addiction}, year={2017}, volume={112 8}, pages={1337-1338} }