Michael Weaver, MD, FASAM.
Professor and medical director at the Center for Neurobehavioral Research on Addictions, University of Texas Medical School.
Dr. Weaver has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
When a patient with a substance use disorder (SUD) has that “reachable moment” and/or recognizes the need to seek help, we know the importance of decreasing barriers to start treatment. However, what is less clear is when to stop treatment. What indicators suggest stable recovery?
Recovery process The DSM-5 definition of remission from SUD is based on the absence of criteria (except cravings, which may persist) from 3 months for early remission to 12 months for sustained remission. The ICD-11 allows for partial remission with significant reduction in consumption and < 3 symptoms, or full remission with abstinence lasting at least 1 month.
12-step groups define recovery as a journey that includes major transformative changes leading to improvements in health, functioning, and well-being, as well as abstinence. The working definition for recovery according to the Substance Abuse and Mental Health Services Administration (SAMHSA) is a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. SAMHSA notes that for those with addictions, abstinence from use of drugs is the goal (www.samhsa.gov).
Measures of outcomes Treatment outcomes studied in clinical trials are evaluated over short periods of time, usually 3–6 months, so long-term significance is unclear. The most widely used set of treatment quality measures in the US healthcare industry is the Healthcare Effectiveness Data and Information Set (HEDIS), but the measures related to addiction treatment focus on initiation and engagement more than outcomes after successful termination. The Addiction Severity Index (ASI), a 155-item structured interview, has been widely used to measure treatment outcomes with subjective ratings of problems by patients and objective lab tests of use; shorter versions of the ASI have also been developed (McLellan AT et al, J Nerv Ment Dis 1980;168(1):26–33).
Measures of treatment success are myriad, but some are more amenable to use during brief clinical visits. I usually include the patient’s subjective reports combined with more objective measurements of substance use. I ask about amount of use, percentage of days spent using, and length of abstinence, including date of last use. I also verify the number of treatment sessions attended or missed. Finally, there are a number of external sources to draw from for objective verification of abstinence, such as urine drug testing, reports from family and peers, and/or achievement of specific goals (eg, return to work or school, avoidance of interactions with the criminal justice system).
Duration of treatment Treatments for addiction, especially those involving medications, should continue as long as the patient is still experiencing a benefit, wishes to continue, remains at risk of relapse, and has no significant adverse effects. Some pharmacotherapy options have a specified duration. For example, varenicline and bupropion for tobacco product cessation are recommended for 3 months after the quit date but can be extended for another 3 months. Some patients may benefit from longer periods on these medications; for example, acamprosate can be continued for a year or more, and after discontinuation of drinking.
Opioid agonist treatment is often a long-term treatment modality, so indefinite treatment is appropriate and may be essential for a proportion of patients. However, patients may want to discontinue addiction treatment for practical reasons, such as scheduling difficulties, transportation issues, financial problems, childcare responsibilities, and job commitments. Patients on opioid agonist maintenance, especially methadone, face disruption to their lives because of strict regulations and burdens imposed by the rigid structure of the treatment delivery system. Often, patients want to stop treatment simply because they want their family members to view them as actively progressing through treatment into recovery. It is important to speak with patients about the risks of tapering or discontinuing medications, given the risks inherent in doing so.
Talking with patients Early in the course of patients’ addiction treatment, I talk with them about how long they may need to stay on medication. Some patients need more time on medication—months to years—because of the severity of their addiction and the harsh consequences of relapse. A longer duration on a maintenance dose can give patients time to work on the behavioral components that they are learning as part of their therapy or in 12-step programs. Other patients may start from a better place—a less severe usage problem and a good support system. These patients might be ready to taper off medication fairly soon after starting (Weaver MF. Opioids. In: Addiction Treatment. Newburyport, MA: Carlat Publishing; 2017). I emphasize to patients that completion of pharmacotherapy does not mean stopping all addiction treatment. There are multiple parts to a successful recovery program, and these will vary over the course of treatment. A patient may stop taking medication, but the other elements of their treatment will continue.
Some of my patients want to rapidly reduce the intensity of their treatment soon after they achieve an initial period of abstinence. After only a few weeks, for example, a patient may want to attend fewer 12-step meetings, see their therapist less frequently, or start coming off of medication. I talk with my patients about getting a “big enough dose” of treatment to help them establish good relapse prevention skills. We have an honest conversation about the likelihood of relapse and the need to devote adequate time to recovery. After all, their addiction didn’t develop overnight. Some people can take years to unlearn the maladaptive behaviors that helped them survive while using. Recovery is a process of replacing old behaviors with new ways to be successful without using substances.
CATR Verdict: Addiction is generally a long-term phenomenon, but most treatments have been tested in the shorter term. Quality measures to determine optimal duration of treatment and successful completion are still in development. Some medications have a recommended duration, such as 3 months for varenicline or 12 months for acamprosate, but opioid agonist maintenance may have indefinite duration. Individualization is necessary. The key is to have an ongoing conversation with patients about when to come off medication appropriately so that they can be well prepared to continue their recovery.