Treatment & Recovery
Each year in the US, conservative estimates show that approximately 20 to 25 million adults suffer from an active substance use disorder (SUD) - Roughly eight to ten percent of the adult population. Yet less than 10% of these individuals receive professional treatment on either an outpatient or inpatient basis, according to data provided by the Substance Abuse and Mental Health Administration (SAMHSA).
The primary factors belying this extremely low treatment rate are cost, lack of enough professional treatment resources, and the intrinsic nature of addiction. Addicts are very reluctant to seek treatment and are unlikely to do so until the disorder has progressed to the point of producing a serious, precipitating crisis event (PCE) in the addict’s life. The pervading societal stigmatization of alcoholics and addicts is also a strong barrier to the allocation, promotion, and utilization of life-saving treatment resources. Lawyers and other professionals are especially sensitive to the stigma of SUD.
SUD rates among lawyers are significantly higher than those found in the general population. Unfortunately, only a small percentage of afflicted legal professionals receive the help they need, with too many continuing to practice at various levels of impairment.
The good news is that we are on the cusp of wider implementation of revolutionary approaches in both understanding and treating SUD across the entire spectrum of the drugs of abuse. While 20 million adults in the US suffer from a current, active addiction, there are over 20 million American adults who have achieved long-term remission.
Primary Treatment Models
Short-term Inpatient Treatment. The most common form of treatment for severe SUD is a standard four-week course of inpatient care at a state-licensed treatment facility. This treatment framework, also known as the Minnesota model, began to be adapted on a widespread basis throughout the US in the late 1950s. As the name suggests, it originated in Minnesota through the efforts of two institutions; the Willmar State Hospital founded in 1907 as a farm for inebriates, and the Hazelden Farm in Center City Minnesota (Now the Hazelden Betty Ford Foundation).
Eighty-five percent of inpatient treatment in the US is based on the Minnesota model. A standard inpatient regime consists of a four-week (28-day) stay at a residential treatment center. Some facilities have medical detox facilities on site, while some require medical detoxification before treatment can begin.
The Minnesota model is heavily rooted in the traditions of Alcoholics Anonymous (AA). It essentially combines a medical and cognitive behavioral therapy approach with the twelve step precepts of AA. All inpatients go through the same program, regardless of their drug of choice. Many people unfamiliar with addiction often think that someone with a cocaine problem for example, can still drink wine with dinner. The prevailing standard of care in addiction treatment is abstinence based. Once one has crossed the line into addiction, refraining from all psychoactive drugs is necessary. Addicts, no matter their drug of choice, will overconsume any drug and remain in active use dysfunction. Addiction changes the neurochemistry of the brain in ways that prevent someone from “learning” moderation. Neurocognitive studies show that addiction causes brain damage that is only restored with abstinence. The good news is the vast majority who maintain abstinence experience the restoration of cognitive deficits caused by addiction, through abstention induced neuroplastic brain change.
The abstinence-based protocol is changing somewhat, primarily as it relates to opiate/opioid addiction, where a medically assisted treatment (MAT) model is gaining traction as a harm reduction approach.
A Day in the Life at Rehab
Each treatment facility has its own particular schedule, but a typical day in inpatient generally looks like the following: Wake up at 7:00 AM, then a brief morning group meeting. Breakfast, followed by a speaker presentation on a particular topic related to addiction, then break up into smaller groups, where a counselor facilitates group therapy discussions. In this setting people talk about their particular problems and triggers. Strategies are taught to deal with emotions and overcoming obstacles to maintaining abstinence.
Following morning group, there is typically a smoke break. Nicotine is ironically, and unfortunately, a staple of recovery. Lunch follows. After lunch, there may be time dedicated to physical exercise, or working on individual assignments given by counselors. Small group resumes in the afternoon before dinner. People often present their assignments to the group during this period. Then, another smoke break followed by dinner. After dinner there is often a session devoted to study of the Big Book of AA, usually followed by an evening break and another presentation. There is usually an hour or two of free time before bed.
Inpatient is exceptionally helpful in a number of ways. It is a safe place. People are out of their using environments, away from intoxicating substances. For many, it’s the first time in years that they have had any clean and sober time. Sleep and proper nutrition are emphasized and available. There is structure that helps dull the din of the chaos that is life in active use.
While in rehab, one receives very useful information that helps raise awareness of how to escape the destruction that is a life lived in addiction. This provides the hope that all of us addicts need to start to change our mindset from one of despair to thinking that it's possible to succeed and get sober.
The connections with others that form is probably the most valuable part of rehab. We all have to share our deepest, darkest secrets and discuss our fears. There is immense emotional healing that comes with vulnerability and catharsis. Deep, healthy bonds form with others in this environment. For most of us, it’s the first time we’ve been able to experience the power of being deeply connected with other humans on an authentic and honest level. Nobody teaches the curriculum of healthy bonding in elementary or law school, but it is a very critical aspect of being a fully realized, productive, and serene person.
Virtually nobody wants to go to rehab, nearly all of us show up very angry and terrified. At the end of four weeks, the vast majority of us dread leaving. In the outside world, we felt an intense sense of isolation and loneliness, even those of us who appear very social, and have families, friends, colleagues and all the indicia of “success.” Our core mindset is still isolation. Our natural state seems to favor the erection of barriers and facades as a dysfunctional mechanism to blunt the intense fear we feel. These self-protection mechanisms are deeply ingrained in most of us with SUD. We live an inauthentic existence, without realizing it, most of which is rooted in how our fear-filled childhood environments formed our fearful adult brains that then coalesced with our genetic propensity to make us choose substance abuse above all else.
Those of us with SUD seem to have a hypersensitivity to fear. Fear is the emotion that is at the root of anger and avoidance (The other AA). Anger and avoidance are humanity’s two most primal, emotive survival mechanisms - To fight or take flight. We need anger to fight, and we take flight to avoid dangerous, threatening, or unpleasant situations. These two foundational emotions are rooted in the human midbrain, and heavily influenced by the neural pathways that control motivation. These are the same neural pathways implicated in addictive disorders. Anyone who has dealt with an addict, and nearly all of us have, know that the conduct of addicts vacillates between overly hostile, angry behaviors, and extreme avoidance of the responsibilities necessary to be connected with family, friends, work and society at large. We numb ourselves to avoid the fear and stress inherent in living a connected, healthy life, and we lose connection to a healthy life by doing so.
The curriculum of rehab is heavily skewed toward teaching strategies that allow us reconnect and properly deal with our fear, anger, and avoidant driven behavioral tendencies. It turns out that being connected with others in an authentic way does wonders in establishing a healthy fight or flight response, blunting the inflamed emotional states that fuel active use as a means of escaping intense, discomforting feelings.
Being connected authentically requires one to be vulnerable and cathartic. It also requires that we be rigorously honest with ourselves, and others when we have made mistakes, and to be humble and fix our mistakes to the best of our abilities. Rehab teaches strategies to live authentically, and honestly, bolstering the ability to connect in healthy ways.
Coming Home
Most of us leave rehab riding a “pink cloud.” We feel good, our bodies have detoxed, we have some clarity, and we have made incredible connections with others. We think we got this! Our families, friends, and colleagues, all expect that we’re fixed. We head back into our old environments after 28 days, with nothing more than discharge instructions that say “Go to AA – Good luck to you.” Roughly 85% of us will fail and relapse, starting another active use cycle. We’ll do well and stay clean and sober for a few months, but most of us can’t make the jump from those crucial supportive bonds we developed in rehab, to forming bonds with new people in recovery in the communities where we live. We loved our rehab treatment group, but those people go back to their lives and those connections fade pretty quickly.
The vast majority of us don’t put the effort into AA or our other aftercare protocols following rehab. We desperately want to be sober, but life gets in the way pretty quickly. Our tendencies to isolate reestablish themselves in short order. We tell ourselves, and others, that we’re doing fine, but our lives at this point are filled with overpowering, subconscious cues, and triggers. Very soon, craving reappears and there isn’t enough of a support or accountability structure in place to act as a barrier to using, so we use. Resumed use has to be more secretive because everyone expects that we're fixed, and we know that failure following rehab has profound consequences. The addicted brain thinks it can get away with it. We become more isolated within ourselves, more fearful of discovery, and more prone to hiding. These renewed active use cycles are profoundly harmful to all involved. With each failure, more recovery capital is lost. Divorce often follows, and job loss is not uncommon. Desperation sets in, leading to ever-increasing levels of aberrant behavior to feed use.
What we know is that people require much more support after discharge from treatment. Accountability structures need to be in place. Family dynamics need work. The addicted brain takes more than 28 days to develop new neural pathways that lead to the eventual establishment of healthy emotional paradigms, and the extinguishment of craving.
Rehab is an exceptionally beneficial first step, but it needs to be augmented with structured aftercare. The pilots and the physicians have shown that aftercare protocols dramatically improve success in achieving long-term recovery. The legal profession needs to do the same, and we’re simply not doing it.
Not All Rehabs are Created Equal
There are approximately 14,500 rehab treatment facilities nationwide. Each state promulgates its own regulations. While most treatment providers follow the Minnesota Model, the approach from a regulatory standpoint is best described as patchwork. It is very much a competitive market dynamic where the vast majority of consumers have little to no experiential framework to evaluate the efficacy of a particular treatment program. Placing a high- functioning alcoholic lawyer in his fifties into a facility where the majority of the inpatients are younger heroin addicts in their twenties is less than ideal. Moreover, most facilities lack the ability to diagnose co-occurring mental health disorders, and many don’t have robust family programs that are critical to augmenting the healing of family members, which also helps the addict maintain abstinence.
The evidence shows that lawyers do far better when in treatment with other lawyers. A recent study estimates that upwards of 274,000 attorneys in the US engage in drinking patterns indicative of alcohol abuse or dependence. Yet there are only a few inpatient facilities in the entire country with programs specifically designed to address the unique needs of legal professionals suffering from SUD. Whenever possible, Vivon enrolls our clients in treatment facilities with legal professional programs. Sometimes that’s not possible given geographical considerations, insurance issues, or other factors. When not feasible, we refer to treatment facilities we have vetted, that meet protocols best suited to promoting the long-term recovery of legal professionals.
Intensive Outpatient Treatment
Those assessed with less severe SUD will most likely start their recovery journey in an intensive outpatient treatment program (IOP). IOP programs are typically conducted during the evening, after work hours, usually for three to four hours a night, four days a week. Program length is usually two to three months. Most IOP programs follow the Minnesota Model. Cognitive behavioral therapy, coping skills training, and AA principals form the basis of treatment. Treatment is conducted in a group setting, facilitated by a counselor trained in chemical dependency.
The benefit of this format is that people can still work and live at home. The workload for an attorney in an IOP setting usually should be modified a bit to accommodate the time commitment. Another benefit of IOP is that urine testing is performed, so abstinence is monitored. The particular IOP facility’s testing program is a critical consideration. Many skimp on rigorous biological monitoring, which is harmful if the testing either fits a predicable pattern or is so sparse that patients can escape detection. Vivon clients who enroll in an IOP are required to immediately commence our biological monitoring program. In our experience, too many IOP programs don’t test often enough to ensure continual abstinence.
For many attorneys, IOP is a good solution, but it is generally only available to those with less severe SUD. If a person has progressed to a later stage disorder, inpatient treatment rather than IOP is generally advisable.
One of the primary benefits of an IOP is that it is local. The majority of communities have an IOP program within close proximity. A major emphasis of most IOP programs is to integrate patients into local AA recovery communities while attending IOP. There tends to be good continuity in the recovery support handoff from an IOP program to longer-term AA attendance. Bonds formed in IOP often translate into continued, mutual, recovery support after discharge
Alcoholics Anonymous (AA)
Alcoholics Anonymous is a primary pathway out of addiction for a significant number of people. Approximately 45% of those who have sought help and resolved a significant SUD problem have initiated their recovery journey through mutual help groups, with AA comprising nearly all of this cohort. A significant number of addicts have progressed to the point where they have little to no financial resources and no health insurance to pay for rehab. AA is free, other than a suggested donation of a few dollars per meeting, and AA communities exist in virtually every community in the country. AA also requires no extended time away from work, a reality when treated at an inpatient facility.
Recovery is very much a grass roots effort. Historically, the medical and mental health professions have had little interest, and little success, in tackling the great challenge of addiction and alcoholism. It has been through the utter desperation of millions of addicts that the overwhelming majority of recovery consists of addicts treating other addicts. AA is the place where that happens.
AA was founded in Akron, Ohio in 1935 by Bill Wilson, a stockbroker, and Dr. Bob Smith, a surgeon. Both men were highly educated, successful professionals, until alcoholism devastated their lives. They discovered that simply talking with each other on an authentic, vulnerable level was extremely effective in curbing their cravings to use.
The “Big Book” of Alcoholics Anonymous was published in 1939. It was a collaborative effort, but Bill Wilson gets most of the credit as the primary architect of AA’s written philosophy. The first section of the book consists of 11 chapters, comprising 164 pages, describing 12 Steps suggested as a path to recovery. The second part of the book describes the individual journeys of people in recovery.
The basic tenants of AA have been around for millennia, and are rooted in principles espoused in psychoanalysis, cognitive behavioral therapy, various philosophical schools, Christianity, Buddhism, Hinduism, and other spiritual traditions. While the veneer of AA is themed in “spiritual” precepts, it provides an effective psychological behavioral modification structure to assist alcoholics and addicts in making the difficult transition out of SUD and into living productive, fulfilled, sober lives.
AA quickly grew from its grass-roots origins to become the leading recovery community worldwide. It is estimated that there are currently 1.3 million people who regularly attend AA meetings in the United States alone. Millions more, who don’t continue to maintain an active affiliation, have taken the AA path out of addiction.
While AA isn’t aligned with any religious sect or denomination, it did grow out of the Oxford Group, a Christian recovery movement founded in the early part of the 20th century. It's likely because of this influence that the 12 Steps mention “God” a great deal, but members are encouraged to view god in their own conception and of their own understanding. The point is to have the alcoholic or addict start living with a mindset that he doesn’t have all- encompassing control over all of the variables and outcomes in his life. Feeling out of control is a primary driver of negative affect states - Anger, resentment, stress, anxiety, depression, etc. These negative emotions tend to cause relapse.
Virtually no addict or alcoholic who arrives at the doors of AA wants to hear about "God." The vast majority of us are agnostic or strident atheists when we arrive, and we remain so in the traditional religious sense. The God piece is typically the most off-putting part of AA for most newcomers, but after some time and experience in the program, most adopt a conception of a power greater than their own self-will. The surrender of self- will and the diminishing of the stress inherent in the self-centric mindset that craves control are critical perspective shifts that are very beneficial to helping alcoholics and addicts develop healthy emotional practices.
Our Western culture trains us to subconsciously believe that if we don't control all the variables in our environments and achieve our desired and expected outcomes, there is something inherently wrong with us. We didn't work hard enough, we aren't intelligent enough, we're not strong enough, or good enough, etc. We come to develop a core belief system that in order to be "good" we must control uncontrollable variables. Living in this construct, without awareness, creates a permeating angst. The spiritual component of AA is very much about accepting that there are forces greater than our individual desires and our will to achieve our expectations. What those other forces are, we don't really know. It could be an old guy with a beard who lives on a cloud in the sky. It could be the Buddha, or it could just be random probabilities determined by the laws of physics. Whatever form we use to perceive this force or forces is irrelevant in the context of AA. The reality is that we can't control all the variables that impact us as individuals. Accepting, understanding, and incorporating this reality into our consciousness profoundly reduces relapse driving negative emotional states.
When we actually contemplate this issue, and bring it into our conscious awareness, it seems silly we believe we can control the myriad of uncontrollable variables we encounter throughout our day, but that is exactly what we semi-consciously expect of ourselves. The bridge goes up, the copier jams, the expert is late with a report and the deadline is today, ad infinitum. We believe the world should work the way we expect it to work so that we can do our part, and get what we want. We believe we are entitled and expected to control these variables. When our environments don't bend to our will to satisfy our expectations, we experience a range of negative emotions: Fear, anger, anxiety, annoyance, depression, etc.
An important part of the spiritual component of AA is simply accepting that we can't control everything and understanding that our role is to merely to engage in the right action and accept the results. Sometimes our expectations will be met, occasionally they will be exceeded, and often, we won't get what we want.
We live in a world of finite ability to satisfy our infinite desires. In AA, we gradually develop conscious awareness that attempting to individually control our way to satisfying all of our desires is futile, irrational, and results in a pervading sense of emptiness and angst. Our purpose, as ordained by God, the universe, evolutionary biology or whatever other force or mechanism, is simply to put effort into doing the right things, rather than obsessing about controlling outcomes. Gradually, the paradox of surrender comes into play. We surrender our attachment to grinding against reality to get what think we want, and focus on just doing, without craving expectation. By surrendering expectations and simply just doing, many of our expectations paradoxically come to fruition. Detaching from expectations and having gratitude for the simplest of things, substantially reduces angst, anxiety and depression, which greatly enhances motivation to continue engaging in taking the right action. Gradually, this psychic perspective shift, or spiritual awakening, through elevation of conscious awareness, leads to a sense of peace and serenity that we had never known before. Our profound fear dissipates. We're far less angry and emotionally volatile, our motivation to continue doing the right things builds, and craving to escape through intoxication diminishes. Connection with others is critical to building this new, healthy mindset. There is no other place like AA to build and foster deep, meaningful connection for those with SUD.
While AA is painted with a Christian veneer and meetings are often held in the basements of Christian churches, it isn't a Christian organization. It incorporates some Christian principles, but it really draws on the whole panoply of psychological, philosophical, and religious tenants aimed at strategies to teach people how to reduce their suffering and find psychological peace. In may ways, the principals of AA are more Buddhist in construct than they are Christian, despite the prevalence of Christian themes, and lack of overt indicia of Eastern spiritual traditions.
AA is loosely organized, without much of a hierarchy or organization. Most meetings consist of a simple format. Usually a topic is chosen from literature, and people share their experience about the topic. Commenting on shares, or offering suggestions during the meeting is discouraged. People are able to talk openly about sensitive personal issues without fear of judgment, and also share about strategies that have worked in particular situations. There is great healing power found in the catharsis of sharing problems openly, in a non-judgmental setting. A great deal of learning also occurs when people collaboratively share strategies and solutions to deal with emotional turmoil. Newcomers are encouraged to try a number of meetings and find a particular group where they feel most comfortable and connected, and then choose that group as their “home group.”
AA encourages members to have a sponsor. A sponsor is another alcoholic or addict, experienced in the program, who is stabilized in long-term sobriety. The sponsor acts as a guide through the 12 steps, a close confidant, and a source of accountability.
The only requirement for membership in AA is a desire to stop drinking. One does not need to follow any set of rules or be sober to attend a meeting or belong to AA. There are no rules per se, merely suggestions. People who struggle to stay clean or sober are welcomed back, over and over and over, and encouraged to keep coming back. All are treated compassionately, with extra support offered for this who continue to struggle.
AA is not limited to people with alcohol addictions. Anyone with a problem involving any drug is welcome. Offshoot groups, very closely modeled on AA, also exist. Narcotics Anonymous (NA) and Cocaine Anonymous (CA) are two of the most prominent organizations to grow out of the AA model. NA and CA members often attend AA meetings interchangeably, and vice versa.
AA is at first, kind of weird. We don’t live in a culture that teaches us to value openness, catharsis and vulnerability when dealing with our problems. This dynamic is especially true of those whose identities are closely intertwined with domineering professions like the law. Alcoholics and addicts tend to be particularly guarded, secretive, and isolated people who deal with uncomfortable emotions by numbing to avoid rather than engaging with healthy coping mechanisms. Those who stick and stay in AA find that they gradually open up to others and become less isolated in their emotional turmoil, which is immensely beneficial to establishing a healthy life construct in thought, feeling, and behavior.
As the name suggests, AA is an anonymous organization. It is very rare that someone is “outed.” This is usually an important concern for lawyers starting on the AA path. The fear of stigma usually dissipates quickly once a lawyer new to AA gets comfortable with the program and the people. There are a large number of lawyers who are members of AA. It is common when attending larger AA meeting to find attorneys participating. There are also a number of lawyer-centric AA groups, although they tend to “off the books” and harder to find for those legal professionals new to recovery.
One of the primary benefits of AA is its ubiquity. AA communities are found virtually anywhere in the United States. An internet search for “AA intergroup” in your area will provide a list of local meetings. Another pro of AA is cost. While a small donation of a dollar or two is customary, meetings are free.
AA is vitally important systemically. It is the aftercare program for the vast majority upon discharge from rehab. Empirical data shows that AA does work for those who put in the work. Unfortunately, most people discharged from treatment do not initially embrace AA, or any other kind of aftercare program, unless mandated by courts or employers. Abstinence and harm reduction rates are significantly higher for those required to attend AA and participate in effective substance use monitoring for at least two years following discharge from treatment.
AA has drawn criticism for not being grounded in science or administered by mental health care professionals. But a recent, exhaustive examination of AA efficacy by professors at Harvard and Stanford universities, using rigorous scientific protocols, found the program to be highly effective (See Study). The crux is to keep the newly recovering engaged in AA at least long enough to allow abstinence induced neuroplastic brain changes to extinguish the phenomenon of craving.
If you’re concerned about your own use, or a loved one, we strongly encourage you to attend a few AA meetings in your area. Most meetings are open meetings, meaning anyone can attend, even the curious who don't have a substance use problem. Just check the legend listed next to each meeting on your local AA Intergroup website to ensure the meeting is open and not otherwise restricted. You will be welcomed and members will be happy to answer your questions before or after the meeting. Just reach out. Keep an open mind and understand that it will seem weird at first, but if you keep coming back, you’ll likely find it invaluable. And no, AA is not filled with derelict gutter bums. You will find wonderful, extremely “successful” people just like you, willing to help you or a loved one confront a deadly affliction.
Lawyers Assistance Programs
All 50 states have Lawyer’s Assistance Programs (LAPs). They are great resource for legal professionals battling substance abuse. They are staffed by wonderful, dedicated people who are committed to helping. They do differ in what they offer. Some have mental health professionals on staff, while others act as a referral source for substance abuse and mental health support. Most have volunteer attorneys in recovery that will act as peer support. The programs are confidential and separate from bar disciplinary departments. Vivon urges and supports the utilization of LAPs. They are a good resource for substance abuse and mental health support in the localities they serve. Local volunteer attorneys in recovery are invaluable in helping newly clean and sober legal professionals begin their recovery journeys. As discussed above, aftercare and monitoring are essential to ensuring abstinence induced neuroplastic brain change leading to stabile, long-term recovery. LAPs generally don’t provide structured aftercare and abstinence monitoring.
Lawyer Assistance Programs
All 50 states have Lawyer Assistance Programs (LAPs). They are great resource for legal professionals battling substance abuse. They are staffed by wonderful, dedicated people who are committed to helping. They do differ in what they offer. Some have mental health professionals on staff, while others act as a referral source for substance abuse and mental health support. Most have volunteer attorneys in recovery that will act as peer support. The programs are confidential and separate from bar disciplinary departments. Vivon urges and supports the utilization of LAPs. They are a good resource for substance abuse and mental health support in the localities they serve. Local volunteer attorneys in recovery are invaluable in helping newly clean and sober legal professionals begin their recovery journeys. As discussed above, aftercare and monitoring are essential to ensuring abstinence induced neuroplastic brain change leading to stabile, long-term recovery. LAPs generally don’t provide structured aftercare and abstinence monitoring.
Individualized Programs
Some seek individualized help from a psychologist or psychiatrist who specializes in addiction treatment. This protocol is usually comprised of one-on-one sessions, conducted in the traditional mental health format, consisting of an hour appointment each week. Most of these mental health professionals will also encourage participation in group recovery programs like AA.
Individual psychiatric and/or psychological care offers the added benefit of assessing and treating potential co-occurring mental health issues that might be intertwined drivers of SUD, or might be masked by SUD. It is helpful for all in early recovery to be screened by mental health professionals to determine the presence of other mental health disorders that require treatment.
Individualized treatment can be a great support tool in recover. Many addicts with the financial means to afford individualized clinical care often try this route as a first response to pressure to get help. In our experience, weekly, individualized treatment sessions alone are usually not enough to produce the mindset shift necessary for the afflicted person to escape the active use cycle. A good body of evidence shows that the primary treatment modality used in this setting – Cognitive behavioral therapy - is less effective than AA and contingency management approaches in fostering long-term remission.
Medically Assisted Treatment
Medically assisted treatment (MAT) is used primarily in the treatment of opiate and opioid use disorders (OUD), although it is also used infrequently to treat Alcohol Use Disorder (AUD). MAT is utilized in conjunction with behavioral modification programs and peer support group participation.
Opiates are drugs that are processed directly from the opium poppy plant. Opioids are synthetic, or partly synthetic, opiate molecules manufactured in the lab. Opium, morphine, codeine, and heroin are opiates because they are derived directly from the opium plant. Drugs such as Vicodin, Percocet, Oxycontin, Hydrocodone, and Fentanyl are opioids. Essentially, opiates and opioids are molecularly the same, without material differences. The various forms of these drugs do, however, differ in their respective potency.
The cravings for opiates/opioids is exceptionally strong and withdrawal from these substances is horrendous. Its very difficult to kick a opioid/opiate addiction, which is why MAT has made strong inroads as a treatment approach since the explosion of the opiate/opioid epidemic.
MAT was originally developed as a treatment for alcoholism, but is used sparingly to treat AUD, largely because MAT is stigmatized in the dominant abstinence based recovery community, and the approach had little efficacy due to a lack of dosing accountability. That's changing with the development of longer-term, time release versions of MAT medications and the growing awareness that the harm-reduction model is a better alternative in certain situations. There is little doubt that abstinence is preferable, but for those who can't sustain abstinence, MAT can significantly reduce the harm associated with continued use, especially where opiates/opioids are the drugs of choice.
Disulfiram, commonly known as Antabuse, was one of the first pharmacological interventions approved by the FDA in 195 to assist in the treatment of alcohol addiction. Antabuse produces a very unpleasant reaction to alcohol, eliminating the euphoric effect of drinking and making one sick when taken with alcohol. It traditionally was administered as an oral medication, taken twice daily. In practical application, it was found that alcoholics simply wouldn’t take their Antabuse to avoid its unpleasant effects and instead drink to satisfy cravings. The drug never gained widespread traction as a medication for the treatment of AUD, most likely due to poor compliance with dose scheduling by patients, and the stigma toward MAT discussed above.
Methadone was approved by the FDA in 1972 as one of the first medications used in the harm reduction model of addiction treatment to assist heroin addicts. Methadone is an opioid agonist, binding to the opioid receptor sites in the brain. It reduces cravings for more powerful street opiates like heroin. It has a much longer half-life than other opiates/opioids, in the neural networks of addicts, producing a less intense effect, but also reducing the phenomenon of craving and the effects of withdrawal. Methadone has the capacity to produce euphoric effects, and it does have addictive potential. It can also cause overdose death. Consequently, methadone's use is tightly regulated. The medication has historically been administered through federally regulated methadone clinics. The goal in any methadone treatment program is to remove the addict from the dangerous use behavior associated with street drugs, and then ideally, to wean the addicted individual off the methadone over time.
Methadone has always been controversial. Substituting one drug for another violates the basic protocol of the dominant abstinence based treatment model. Methadone's strict regulation makes access more difficult for those populations who benefit from reducing the dangers associated with the use of heroin and other illicit opioids/opiates. But, In most cases, it’s easier for the addict to get heroin than access methadone and stay compliant with methadone treatment requirements. Quality studies show that methadone does reduce HIV, hepatitis, and overdose death in the aggregate. But, like heroin and opioids, methadone is a difficult drug to wean from.
With the explosion of the opioid epidemic in recent years, other pharmaceuticals have started to gain traction as treatment adjuncts. Buprenorphine is a partial opioid agonist that, like methadone, binds to the brains opioid receptors. It is less powerful than methadone and has less potential for misuse, but it is still highly regulated. Physicians must be certified by the Center for Substance Abuse Treatment before they can prescribe buprenorphine. Like methadone, buprenorphine has a longer half-life than street opiates, binding to opioid brain receptors for longer periods of time, reducing craving and withdrawal symptoms. Buphrenorphine is best known by its most common trade name, Suboxone. It is administered sublingually, usually by the patient, without direct observation of medical personnel. Subscriptions tend to be written for a small number of doses at a time, allowing treatment providers to more closely monitor the patient.
Naltrexone is a medication that is an opiate antagonist that was approved by the FDA for opioid dependence in 1984, and for alcohol addiction in 1995. It blocks the opioid receptor sites in the brain, preventing the euphoria experienced when opiates /opioids are ingested. It also works as an antagonist in AUD patients, blocking the euphoric effects of alcohol.
The antagonist approach to MAT aims to eventually extinguish use. When the addict uses to seek euphoric effect, ingesting the drug no longer works because the receptor sites in the brain are blocked. Over time, the addict’s drug seeking behavior diminishes when the expected neurological reward is no longer received. The addicted brain learns over time to associate pleasure with drug use, leading to compulsive use in the face of harmful consequences. By removing the pleasure associated with use, the brain disassociates use from pleasure, extinguishing drug taking. There is evidence that this approach is effective for some addicts and alcoholics, but it still isn’t widely used. In the past, addicts and alcoholics tended not to take the medication. The advent of time-release features now incorporated into administering these medications, may significantly improve the efficacy of this approach.
Recently, new medications have come into use that contain an extended release feature. An addict will get a shot, usually once a month, administered at a doctor’s office. This approach has the great advantage of taking daily medication management out of the hands of the addict. Vivitrol and Sublocade are brand name medications of extended release MAT interventions. Sublucoade is a buprenorphine extended release and Vivtrol is an extended release version of Naltrexone.
The hybrid MAT approach is another recently developed MAT protocol. It combines medications that contain both an agonist and antagonist. Subutext is a brand name medication that contains both buprenorphine and naltrexone. It’s designed to reduce craving and withdrawal symptoms while blocking the euphoric effects of the stronger opiates of abuse.
MAT is the proper approach for many with opiate/opioid addictions. These drugs are exceptionally dangerous and very difficult to quit. The harm reduction model embodied in the MAT approach has saved the lives of many with OUD, and allowed a great number to eventually achieve abstinent remission.
Unfortunately, the legal profession isn’t immune to the opioid epidemic. There is evidence that lawyers consume opioids at a greater rate than the general public. Those who specialize in the treatment of lawyers report that they are seeing a sharp increase in the number of attorneys entering rehab, whose primary drug of choice is opioids. MAT may be warranted as a treatment protocol for attorneys with opioid/opiate addictions.
There are other pathways to recovery, and recovery isn’t necessarily a one-size fits all proposition. Certain things click with different people. A few key constructs seem to permeate any recovery success story - Structure and connection with others in recovery. Monitoring, accountability protocols, and appropriate support, leveraged correctly have proven to be exceptionally efficacious in helping achieve stable, long-term recovery. Facilitating the best chance of achieving long-term recovery for legal professionals is our life’s work at Vivon. If you, a colleague, a loved one, or a friend needs help, please contact us. We’re here for you.