Medication-Assisted Treatment for Opioid Addiction in the United States: Critique and Commentary

ABSTRACT

In the United States, buprenorphine products (namely buprenorphine/naloxone combination) and methadone are the primary forms of medication-assisted treatment (MAT) that are authorized for addressing opioid addiction. Although treatment ideologies differentiate MAT programs, much of the provision in the US reflects a model of “high threshold, low tolerance.” This model is discussed with a focus on structural and programmatic barriers that shape access to and retention in MAT. The critique continues with a discussion of multifaceted stigma that reinforces spoiled identities and diffuses into treatment settings. The social control mechanisms that are imposed in MAT are strikingly similar to those reflected in criminal justice settings, namely probation, parole and community corrections more generally. Parallels are drawn between the “addict” and the “felon” and how they are monitored, tracked, and controlled. These factors have major implications for recovery.

KEYWORDS:

• Medication-assisted treatment
• opioid dependency
• addiction
• methadone
• buprenorphine
• stigma
• identity
• high threshold/low tolerance

Acknowledgement

Many thanks to Andrew Rosenblum and Herman Joseph for their helpful suggestions on an earlier version of this paper. An earlier version of this paper was presented at the 2016 annual meeting of the Academy of Criminal Justice Sciences, Denver.

Declaration of interest

The author reports no conflict of interest. The author alone is responsible for the content and writing of the paper.

Notes

1 I learned this concept from two community outreach workers in Belfast where I worked for 17 years. Iain “Buff” Cameron and Chris Rintoul used the phrase “high threshold/low tolerance” to refer to the rules and regulations imposed by some homeless shelters that attempted to exclude people who were both homeless and experiencing drug (namely heroin) addiction.

2 Treatment attrition is also high in programs that do not provide medication-assisted treatment. Among people addicted to opioids, however, attrition tends to be substantially higher for those who do not receive MAT compared to those who do (see for instance, Kakko, Svanborg, Kreek, & Heilig, 2003).