Abstinence or Maintenance?


A pair of opinion pieces in the British Medical Journal highlight different approaches to the medical profession's role and appropriate care in the treatment of heroin addiction.

Some specialists and government programs lean toward abstinence as the only outcome worth funding, while others see good results with methadone for narcotic replacement therapy.

The reason for the reactions on the pages of Britain’s most prestigious medical journal is in response to the UK government’s decision to travel the abstinence path – focusing on getting patients off heroin instead of substituting methadone for long-term stability.

This parallels how methadone is currently used in the U.S. as maintenance, but with the goal of progressing toward getting off methadone (just as addictive as heroin) and then, hopefully, off opioids altogether.

While the promise of abstinence is full recovery, the risk is that patients will simply return to street drugs when they feel too much pressure to change.

Advantages of Maintenance Therapy

In Dr. Jason Luty’s piece, he says, "any suggestion that detoxification is as effective as maintenance is poppycock." Maintenance therapy offers two clear advantages: The first is that more addicts are willing to alter their behavior (moving from IV heroin to oral methadone) if they know they won’t have to suffer withdrawal.

This leads to the second advantage – addicts who would otherwise be invisible to the healthcare system can be seen, evaluated and receive treatment for other conditions, with HIV and other infections prominent in this population. The combination leads to what maintenance supporters refer to as “harm reduction treatment” rather than “addiction treatment,” which would focus on cognitive behavior therapy and abstinence.

A 'Restaurant Menu Solution'

On the other side is the opinion of two New York doctors, brothers Arash and Kamiar Alaei, also addiction specialists. They are not against maintenance therapy but put it in a broader mix, preferring a “restaurant menu solution.” They write, “to reach more people and to achieve the desired results we must have a more comprehensive program, offering a wide range of options for treatment, harm reduction, and recovery.”

In the end, both articles want the same thing – less government interference and more power to treat their patients in the best way they know how. All the doctors agree that prison is not a solution to addiction and that treatment requires the willing cooperation of the addict.

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