Commentary: A New Paradigm for Substance Abuse Treatment

Substance abuse treatment is committed to abstinence from nonmedical drug use. Yet, continued nonmedical drug and alcohol use and relapse are so common that they are often defined as part of the disease itself.

A “new paradigm” for care management has been pioneered over the past four decades by the state Physician Health Programs (PHPs).1 PHPs provide diagnostic evaluation, treatment referral, close monitoring and support services to health care professionals who have conditions, including in particular substance use disorders, which can impair their ability to practice medicine with reasonable skill and safety. In dealing with substance use disorders, PHPs use a zero tolerance standard for any alcohol or other drug use, enforced by intensive random testing and close linkage to the 12-step programs of Alcoholics Anonymous and Narcotics Anonymous to produce remarkable long-term outcomes. These outcomes set a far higher standard for success in treatment and they cast doubt on the definition of addiction as being characterized by relapse. They demonstrate that the environment in which the decision to use or not to use alcohol and drugs is a powerful determinant of outcomes.

PHPs use frequent random drug tests with panels covering 20+ substances often including advanced alcohol tests which can detect recent use up to six days after alcohol consumption. Each day, physicians call a telephone number to learn if they are required to be drug tested that day. There are immediate and serious consequences for a positive test or for any other noncompliance with the program, including skipping tests. Noncompliant physicians are typically removed from medical practice and are admitted to more intensive treatment under even more intense monitoring.

The first national study of the physicians in 16 state PHPs showed that over the course of five years of monitoring, 64 percent completed their monitoring contracts, 16 percent signed new contracts or extended their contracts and 28 percent did not complete their contract.2 Among the physicians who completed or extended their contracts, 81 percent had no relapse during the five years of monitoring. Among the physicians who had at least one positive drug test, 74 percent never had a second positive. The overall positive rate was about one half of one percent, meaning on average, one in 200 tests were positive for any alcohol or drug use.

The lessons learned from the PHP experience are widely applicable in many other settings including drug-free workplace programs. Physicians in PHPs have a lot on the line, including their careers. It is in the interest of these physicians to become drug- and alcohol-free and resume their medical practices. The same can be said for employees who participate in workplace recovery programs.

While some may dismiss the PHP results because physicians are a uniquely advantaged patient population, a similar approach has produced outstanding results in a dramatically different population of addicted people — convicted felons on probation. A randomized control study of the pioneering HOPE Program showed that compared to a control group of standard probationers, HOPE participants were 55 percent less likely to be arrested for new crimes, 72 percent less likely to use drugs, 61 percent less likely to miss appointments with probation officers and 53 percent less likely to have their probation revoked.3 HOPE probationers were sentenced to 48 percent fewer days of incarceration.

The new paradigm of long-term monitoring with swift, certain and serious consequences for any detection of drug or alcohol has the potential to substantially improve long-term outcomes for substance abuse treatment.

Robert L. DuPont, MD
President, Institute for Behavior and Health, Inc.

1DuPont, R. L. & Humphreys, K. (2011). A new paradigm for long-term recovery. Substance Abuse, 32(1), 1-6.

2McLellan, A. T., Skipper, G. E., Campbell, M. G. & DuPont, R. L. (2008). Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. British Medical Journal, 337:a2038.

3Hawken, A. & Kleiman, M. (2009). Managing Drug Involved Probationers With Swift and Certain Sanctions: Evaluating Hawaii’s HOPE. Washington, DC: National Institute of Justice, Office of Justice Programs, U.S. Department of Justice.

19 Responses to Commentary: A New Paradigm for Substance Abuse Treatment

  1. RJs Mom | February 3, 2012 at 12:47 pm

    It’s nice to finally read something that makes sense. Imagine that, using a 12 step program, not throwing more pills at someone. What is the success of “curing” drug addicts by throwing more pills at them. 12 step programs are more effective because they work…without using drugs.

    • Nan Davis RPh, CCP | February 3, 2012 at 6:46 pm

      Bravo. Drug free treatment is a message whose time has come –Again! One hopes it will penetrate colleges of medicine and pharmacy in spite of deep pockets funding training that: “scientific means treat with medication”

    • Carlos | February 9, 2012 at 4:30 pm

      Imagine that, using a 12 step program, not throwing more pills at someone. What is the success of “curing” drug addicts by throwing more pills at them. 12 step programs are more effective because they work…without using drugs.

      The rate of Methadone and Buprenorphin is quite high. Even higher than AAs imagine that. Contact SAMHSA and find out, you may even want to read the FREE Treatment Improvement Protocol for both. The data is there. I know, I have done it myself so I have both anecdotal and rigorous studies. AA has not data, and you guys keep saying only 2 out of 100 is going to make it.
      I am wondering when is Substance Use disorder treatment going to be base on science, like all the other medical conditions we call treatment. We should all remember to do what you say because you blindly follow biases. Learn a little science and keep coming back when you pass high school biology.

  2. Frederick Rotgers, PsyD, ABPP | February 3, 2012 at 12:54 pm

    Once again we have an otherwise thoughtful and knowledgeable professional in the field confusing healthcare with sanctioning (in a sense criminally and legally) behavior that is potentially harmful to others. While there is certainly a case to be made for having sanctions imposed with respect to behavior that genuinely creates a situation in which a healthcare provider is a danger to his/her patients, I wonder if it is actually swift and serious consequences that are making the difference. As Dr. DuPont notes, large percentages of clients in both of these studies fail to respond to those sanctions. Are these all merely psychopaths who should now be punished for bad behavior, or is there a more health-related (or perhaps system failure related) reason for their failure to respond to serious and swift sanctions? We are too quick in this country to blame the patient for treatment failures, especially in addictions treatment. Is failure NEVER the result of an inappropriate match of treatment to the particular client’s needs?

  3. Bill Poel | February 3, 2012 at 1:02 pm

    As a corrections professional for over 35 years, this “new paradigm” is certainly not new. Physicians certainly have incentive to make this work if they want to keep their license. I would certainly need much more information on the HOPE Program that describes all those wonderful percentages of this and that relating to people on probation. Who were the probationers, what were the offenses, how long was the study for, etc. There are many unknowns that would need to be addressed for credibility’s sake.

  4. Leslie Basden | February 3, 2012 at 1:50 pm

    As someone has already mentioned, there is nothing new here.

  5. Tony Graveline | February 3, 2012 at 2:20 pm

    long term accountability and becoming a part of the medical field is the success of this. 12 steps is a good support, but the medical monitoring and accountability after counseling is crucial. Wrap around services work for children, they also can work with adults.

  6. Marcia | February 3, 2012 at 2:24 pm

    A “new paradigm” for care management has been pioneered over the past four decades… coincidental that that’s the same amount of time we’ve had the beyond-belief stupid “War on Drugs”? A trillion dollars spent since its inception. The profiteering Industries are raking in money and are addicted. How’s that going for you all?

    At the beginning of every Alcoholics Anonymous meeting…

    From the number of persons under control of the U.S. criminal justice system with a conviction for “drugs” as their most serious offense. It shows that in 2009…

    Pretty impressive numbers, huh? Mass Incarceration isn’t it wonderful. I’ll let you in on a little secret. There are drugs available anytime and anywhere in our Lock up System. Then we have the US Office of National Drug Control Strategy estimated federal spending on substance abuse treatment and treatment research:

    $3.566 billion in 2010 (requested)
    $3.415 billion in 2009 (enacted)
    $3.244 billion in 2008
    $2.943 billion in 2007
    $2.942 billion in 2006

    “In 2008, 4.0 million persons aged 12 or older (1.6 percent of the population) received treatment for a problem related to the use of alcohol or illicit drugs – and you know that doesn’t even scratch the surface. The country’s more than 2,100 drug courts were estimated to have roughly 55,000 participants in 2008,37 representing a tiny fraction of the more than 1.6 million people arrested on drug charges every year. That is, there is one drug court for every 26 drug court participants – and, for every one drug court participant, there are 29 other people arrested for a drug law violation who are not in a drug court.”

    After all that great news, we haven’t even touched on the impact of the children left behind. The cost of funerals. The crime rate increase because of our intolerance, forcing an underground cartel. Not to mention the insane profits of big pharma, the prison industry and so many others profiting at the expense of fairly helpless individuals. Maybe time to try something different? Like legalizing and regulating Cannabis, then taking that revenue to increase programs for education, rehabilitation and harm reduction?

    Think about it, how much worse could it be that what we have?

  7. notwhatyouthink | February 3, 2012 at 2:43 pm

    I like the ideal that treatment would dictated no mind altering drugs even is prescribe. I disgree that forcing and threatening is effective as a treatment. Ya, CLT’s will sometimes comply while in treatment, but when the threat is removed, their back using again….how many times have I seen this senario play out over the past 30 years.

  8. Brian | February 3, 2012 at 4:06 pm

    Who is going to pay for all of the extensive and expensive drug testing? Affordable for physicians, but probably not for many others.

  9. Jim Sharp | February 3, 2012 at 4:12 pm

    This report reinforces previous lessons we have learned such as, “When you are dealing with a chronic, incurable disease characterized by relapse, the treatment must continue or the disease will win.” The treatment, it appears, in this report consisted of participation in 12-step programs and random testing with higher levels of care if indicated by positive test results. So, in this instance, the CHRONIC disease of addiction was NOT treated (unsuccessfully) as an ACUTE illness and there were high rates of success (surprise). I do share Dr. Rotgers’ concerns about the use of sanctions. It might be interesting to see if person-centered, motivationally-based approaches with few or no sanctions could approximate such success.

  10. karen | February 3, 2012 at 11:11 pm

    The physicians have a good success rate and appear to be well aware of the inherent danger of addiction and alcoholism, unlike many other people in mainstream America. The doctors evidently know enough about the harm of addiction to take a stand for their own and want them clean and sober, not off to the methadone clinic or the seboxone clinic or on a smorgasbord of other prescription substitutes. Good for them. They should know what’s the best course of treatment. I hope they take a stand for the countless other sick and sufferring addicts and alcoholics, who can’t think straight are un or undereducated and unemployable, by joining with many other American people who would like big pharma to stop flooding the market with highly addictive opoids that should be tightly regulated in the medical community.

  11. Ben House | February 4, 2012 at 12:57 am

    New and four decades seems inconsistent. This sounds like behavior mod with lots of attention given to participants, all with controlled and significant consequences. My primary concern is the continued perception the primary problem with addiction is limited to substance use. That must be addressed, but I believe the substance use is an attempted solution for the core problem. See the work of Earnie Larsen.

  12. cigarbabe | February 4, 2012 at 1:18 am

    Punitive measures never work well when dealing with drug/alcohol abuse. All you end up with are people who resent having their lives dictated by a counselor/clinic where the staff usually is barely qualified. The turnover rates for these “counselors” is 87% last time I looked in Ma. Why waste all that money being spent to punish and incarcerate drug users who are typically non violent and are just trying to keep from becoming ill from their drug habits? We still don’t have treatment on demand in this country and we continue to waste billions of dollars that could be used elsewhere to better serve people who are desperately needy and impoverished. When will we stop all the useless funding on this insane “war on drugs” and use that money to help people truly in need? Drugs should be available and taxed for adults who can pay for them eliminating the need for cartels and a blackmarket for drugs. They just waste the lives of those they employ and they are the ones taking the huge chances of getting caught and jailed. We seldom see any traffickers or “bosses” being locked up.

  13. Howard Clark | February 4, 2012 at 2:10 pm

    Or, could it be that when Health Care Professionals enter treatment that they are cognizant from the outset that monitoring, possibly sober housing, and AA and NA involvement will be required? Thus inpatient treatment is not centered on whether to remain abstinent or not. Rather it becomes important to learn: “How can I do this?” Does this not add to the standard of rarely having seen a person fail who has followed at least some kind of path?

  14. Greg Elam,M.D. | February 4, 2012 at 5:54 pm

    I have monitored physicians,dentists, nurses, lawyers and general workplace employees using the daily call in system for several years now. I am convinced that the daily act of calling is a crucial piece because of the forgetting nature of the disease. How many other diseases would be better served by having the patient call in every day to be tested for cholesterol or blood pressure for example? Daily accountability may rely on fear to stay clean for a while, but the discipline of it imprints. I have had several people ask to keep calling after their contract is up. AA teaches that the one who needs the help makes the call, and this mirrors helping people break out of the isolation and be part of something greater. This is not new, but it could be more broadly applied . The expense is nominal compared to the testing alone.

  15. Michael Abbott | February 5, 2012 at 6:05 pm

    Promoting the idea that addiction doesn’t involve the risk of relapse is like saying that the diagnosis of diabetes doesn’t involve hypergycemia. Someone show Dr. DuPont the diagnostic criteria for addiction.

  16. doogiem | February 6, 2012 at 3:56 pm

    Mr. DuPont:
    Read your history. Start with William White’s Slaying the Dragon. Your “new” paradigm is the old one (the Minnesota Model, circa 1952) with five years of sanctions (“swift and corrective monitoring” as you say, which you soft-pedal as the coercive “environment in which….to use or not…”).
    Like it or not, no one in this country can speak for the field of behavioral health addictions treatment. Why? Jack Henningfield, Patricia Santora, and Warren Bickel write in the epilogue to their 2007 Addiction Treatment: Science and Policy for the 21st Century: “Like all public health problems, addiction is a complex one, with multiple causes, multiple prevention strategies, and multiple cures….there is little apparent consensus among the experts. The issues span nomenclature, theoretical perspectives, diagnostics concerns and determining appropriate treatment interventions.”
    The real, true, modern behavioral health paradigm tells me this: that I help the addict learn and apply the essence of recovery to the particulars of their life – their medical/neurological and psychological condition(s) as well as their particular cosmology and sources of inspiration (secular, philosophical, spiritual, or religious). The old paradigm speaks otherwise. I, for one, am living in the modern world.

  17. perryrants | February 14, 2012 at 12:40 pm

    i cannot agrees with you more. over the past 25 years i have advocated the “strictness” of abstinence as an opportunity to do something. the battle was never the client, it was/is always staff who made/make excuses for client behaviors-including the silly notion that it is “part of the disease”.

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