Moving Beyond the Medication or Psychosocial Treatment Dichotomy to Address the Opioid Epidemic

Although there is an idiopathic etiology and a course of any given opioid use disorder, a broad and exceptionally well-documented consensus indicates that the gold standard of treatment is medication (i.e., methadone, buprenorphine, naltrexone) (2). Meanwhile, there is insufficient evidence on the use of any specific psychosocial intervention to treat opioid use disorder, either alone or as an adjunct to medication. Nevertheless, in many settings that serve marginalized communities, access to medication is significantly limited and is often provided only when an individual engages in counseling or other psychosocial resources. Compared with the general population, the prevalence of opioid use disorder is higher among people involved in the criminal legal system. However, as recently as 2018, 20 state departments of corrections did not offer medications in their drug treatment programs, and fewer than 200 (of over 3,000) local jails provided medication, with the most common (injectable naltrexone) being the least effective (3). In community settings, people of color are disproportionately prescribed methadone instead of buprenorphine, leading to a far higher bar for access and increased cost and travel barriers that compound difficulties with gaining employment or receiving job training. Enhancing equitable access to care is a public health imperative, including integrating access to medications for opioid use disorder into medical settings that are easily accessible by underserved communities (see an online supplement to this Viewpoint).

It is hard to read this evidence without wondering why these disparities exist and why, despite the overwhelming support for medication, incarcerated and minority communities lack access to lifesaving treatment. Withholding access to medication is an approach that is not widely used in any other medical treatment area. A psychiatrist may recommend therapy to a patient with chronic depression but would not withhold a selective serotonin reuptake inhibitor if clinically indicated. A primary care doctor would strongly encourage a diet-and-exercise regimen for a patient with diabetes but would not withhold insulin if it was needed to stabilize blood sugar.

This is not to say that counseling or other psychosocial interventions are unimportant to recovery, but their efficacy varies widely, and they are not supported as independently effective treatment strategies for opioid use disorder (2). Therefore, requiring patients to engage in psychosocial interventions in order to receive medication is unethical and unjustifiable. The treatment approach to depression or diabetes is focused on saving lives so that patients have the opportunity to engage in other interventions that will help them recover and thrive, whereas the treatment approach to opioid use disorder forces patients to prove they are worthy of receiving treatment. Withholding medication increases symptomatology, which impedes a patient's ability to engage in treatment, turns psychosocial services into a form of punishment, and is not evidence based. In fact, in both carceral and community settings, the evidence indicates that providing access to medications for opioid use disorder without additional treatment requirements increases engagement in the psychosocial regimen (4, 5).

When the physiological effects of opioids are not treated quickly and consistently, people die. This happens at staggering rates for those reentering the community after release from prison: abrupt cessation and poor withdrawal management while in custody can lead to overdose when returning to prearrest usage. Overdose also remains a significant concern in the general population, where opioid use leaves individuals at risk for exposure to fentanyl. It is neither flippant nor dismissive to say that dead people cannot engage in counseling. Providers often cite the risk of medication diversion or drug substitution as a reason for restricting access to medications, but such concerns become unmeaningful when compared with loss of life. Treatment providers and patients can collaborate to address medication diversion and other concerns while treating a concurrent substance use disorder, but withholding lifesaving medication puts patients’ lives at risk.

Making counseling a prerequisite of pharmacological treatment is replete with the risks associated with making a moral rather than a medical decision. That moral judgment comes at the expense of human life and freedom and disproportionately affects marginalized communities. There are many important considerations, including treatment planning, comprehensive assessment, targeted education of patients and providers, targeted attempts to reduce stigmatization, and patient preferences, and all should be brought to bear when working holistically with any patient. Multiple attempts should be made to help someone with opioid use disorder engage in the panoply of resources that promote recovery. However, a patient reluctant to engage in any modality of treatment should not be punished. Instead, reluctance should be clinically and meaningfully addressed in a person-centered way, with recognition that the patient has an important voice in the process and with an emphasis on collaborative treatment planning.

In response to the disparities and stigmatization described above, much lip service has been paid to “person-first” language. Although improving the language we use is an important and welcome development, tethering medication to counseling flies in the face of the theoretical underpinnings of person-first care. For example, person-first language often respects the worth and dignity of all persons. Yet, disparities in access underlie discrepancies in how worth and dignity are perceived in different populations. This rhetorical shift should also come with an emphasis on person-first treatment. First and foremost, medication should be easily and equitably available to all people with opioid use disorder. This does not mean that medication should be forced on anyone, but it also should not be withheld for any reason other than a documented clinical justification.

Several empirical reviews support medication provision, and models to improve medication access have been developed. One jail- and community-based model is “Medication First” in Missouri, which untethers provision of medication for opioid use disorder from any other prerequisite of receiving lifesaving care (6). Another prison-based example is in Rhode Island, where all inmates are screened for opioid use disorder and offered a choice of methadone, buprenorphine, or naltrexone (7). Recently, the Bureau of Justice Assistance published a legal brief highlighting the legal and regulatory imperative of appropriate withdrawal management and recovery support for those with substance use disorder in jail settings. The brief emphasizes maintaining consistency with appropriate clinical standards, including continuation or initiation of medications for opioid use disorder (bja.ojp.gov/doc/managing-substance-withdrawal-in-jails.pdf).

Let us be clear that this Viewpoint is not meant to address the moral intentions of those who promote counseling and psychosocial services. Yet, dogmatic adherence to requiring such services as a prerequisite of medication provision creates a barrier to accessing a lifesaving pharmacological intervention, which contradicts the scientific evidence base and the principle of equity of access to care. We must break down this barrier to care to follow the science and save lives.