A study was published in the Archives of General Psychiatry this week with the aim of determining the effects of counseling on addiction treatment with and without maintenance medications like buprenorphine. The results and the response to the study were, for me, completely unsurprising. The abstract linked above reported that counseling had no significant effect on patient recovery at any stage of research, and that treatment with buprenorphine and naxolone produced a tenfold increase in the number of patients with “successful outcomes”. Once medication was tapered off, success rates returned almost to baseline (8.6% successful outcome, compared to 6.6% successful before beginning medication). The study concludes that “[p]rescription opioid-dependent patients are most likely to reduce opioid use during buprenorphine-naloxone treatment: if tapered off buprenorphine-naloxone, even after 12 weeks of treatment, the likelihood of an unsuccessful outcome is high, even in patients receiving counseling […].”
The results of this study are unambiguous. It is concrete evidence for what I have been saying to my colleagues and patients for years: counseling, while it has its place in patient care, is not a sufficient or even particularly effective treatment for the medical condition of opioid dependence. This is not revolutionary or counter-intuitive. There is no chronic medical condition on Earth that can be cured by counseling alone. Neither high blood pressure nor diabetes would show a counseling effect if tested in a similar study. Yet officials in the field of addiction continuously demand counseling as the sign of a valid treatment strategy.
What really surprises and upsets me about this study is the reaction to it, as expressed in this article from Addiction Professional. The very first paragraph of the article cautions that because the results for counseling were “disappointing”, the study required a “careful read” and in fact “should not be interpreted as diminishing any role for talk therapy”. Never mind the fact that counseling has been empirically shown to be ineffective when not combined with a well-informed medical treatment strategy; never mind that, even before this study, counseling-based addiction treatments have had abysmal success rates for decades. None of that is any reason to think there might be a diminished role for talk therapy!
I do happen to think that talk therapy should take diminished role in addiction treatment, but that isn’t even the most upsetting part of the article. It goes on for several paragraphs to express surprise at the fact that, once the medication was taken away from the patients, many stopped doing well; this culminates in one of the final sentences, in which a quote from Roger D. Weiss of Harvard Medical School blames the patients for the failure of counseling to make a good showing in this study.
Weiss’ quote implies that the counseling failed to make a difference because “[Patients] wanted the medication — that’s what they were there for.”
This trend, of blaming patients for not wanting to improve, is a despicable and predatory practice that goes back to the earliest days of addiction treatment, and would never be tolerated in any other field. It’s one I have written about a great deal, so I won’t go into again here, except to say that a more medication-based approach to addiction treatment would do a great deal to weed this idea of sickness as a moral failing.
The study published this week did a great deal to advance the study of addiction treatment, and it is my fervent hope that as time goes on this data, like all empirical data, will be used to create a more effective and comprehensive system of treatment in this field.