A new study indicates that abstinence-based inpatient addiction treatment fails to reduce drug poisoning risk.
Even worse: abstinence-oriented treatment may be associated with higher rates of opioid poisoning than no treatment at all.
The Connecticut study analyzed 965 opioid poisoning deaths from 2016 to 2017, the approximate moment fentanyl hit the illegal market there. The deceased people had recently undergone one of several conditions: no treatment; medication-based (buprenorphine or methadone) treatment; or short-term (less than 14 days — essentially referring to detox) or long-term (longer than 21 days) addiction treatment in which medication was not provided. The study reinforced previous findings that “meds, not beds” is the evidence-based approach to reduce opioid poisoning risk.
This does not mean abstinence does not work for some people or that inpatient options should not be made available, but we need to be more scrupulous about mental health and addictions budgets — for example Alberta’s, which designates hundreds of millions in capital and operating expenses for each of the next three years to build and run largely privatized addiction facilities.
In a political climate where governments seem content with appearing to do something about drug poisoning, advocating for expanded residential treatment and detox — despite their inability to reduce death rates — while the Alberta government continues to flirt with forced abstinence, could be actively causing harm.
In Alberta, we spend at least 10 times more on residential treatment than we do on supervised consumption. This gap is only widening as the United Conservative Party continues to defund harm reduction in favour of institutionalizing people who use drugs, while finding new ways to convey their message to their designated stakeholders.
In April, Calgary will be treated to another provincially funded Recovery Capital Conference, the recovery industry’s central propaganda and deal-striking forum. (As an experiment, try searching any right-wing politician’s X handle with the word “recovery,” which has been hijacked as a stand-in for “abstinence.” You might be surprised by how much rent it commands. Here’s a starting point with Premier Danielle Smith.)
B.C. is hardly better, with its minister of mental health and addictions touting the province’s 3,200 treatment beds while contributing its own sponsorship dollars to this fall’s Recovery Capital tour, despite the lack of evidence that the events deliver value.
It’s agonizing to watch the B.C. government tie itself in knots to avoid making correct drug policy decisions. Safe supply has reached a tiny fraction of people at risk of poisoning, and the province’s short-lived experiment with decriminalization has been rolled back after continued pressure from police and their political allies. (The latest legislation on public use is being challenged in court by the Harm Reduction Nurses Association, represented by Pivot Legal Society.)
Alberta and B.C. lead all other provinces in drug poisoning death rates. Despite the lip service paid to harm reduction in B.C., its budget remains fundamentally abstinence oriented.
Meanwhile, Alberta has abandoned lip service altogether, emphasizing through repeated political overtures its focus on its recovery-oriented systems of care.
Drug poisoning is no different: we continue making room for politicians, media and even many advocates to misdiagnose and mistreat the biggest killer of young people in this country since the Second World War.
Reinforcing the recent study on abstinence-based inpatient treatment, a sweeping 2020 peer-reviewed study of over 40,000 people diagnosed with opioid use disorder in the United States found that of six assessed treatments, only outpatient buprenorphine or methadone treatment protected against overdose or downstream opioid-related acute care.
The other treatments (inpatient detox or residential treatment, outpatient medication-assisted with naltrexone, inpatient counselling, outpatient counselling or no treatment) showed no statistically significant effect.
When I brought this up with Alberta’s Ministry of Mental Health and Addiction, it responded that this 2020 study doesn’t reflect the “Alberta model,” which provides rapid access to medications and integrates these into residential treatment facilities. (It doesn’t, actually — about 40 per cent of residential treatment spaces and 40 per cent of detox spaces restrict various medications.)
Regardless of the integration of medications into these inpatient programs, if outpatient medication programs provide the same or better outcomes, why are we building so many “recovery communities”?
If you are conducting advocacy on drug policy, you should be well versed on five critical research findings of 2023. If you are not, I implore you to follow the links below and consider how they align with what you are saying publicly.
- Abstinence-based addiction treatment does not reduce drug poisoning risk and could create higher risk than no treatment.
- Drug confiscation by police is followed by heightened drug poisoning in a 500-metre radius around the bust for weeks following.
- Safe supply reduces drug poisoning and petty crime among those enrolled.
- Encampment evictions increase drug poisoning risk for people who inject drugs.
- Overdose prevention sites and syringe service programs are not associated with higher crime.
We continue to see right-wing advocates moving the goalposts on these discussions. Adam Zivo has adopted this role at the National Post, for example, by reformulating criticism into victim narratives.
To these folks, it doesn’t matter if their arguments are rooted in evidence: the point is to delay expansion and implementation of badly needed programs and services to buy enough time to elect a more harm-reduction-hostile federal government.
Many of these advocates likely also recognize the possibility of the public waking up to the golden opportunity to reallocate municipal, provincial and federal budgets from police to social safety nets that have been decimated over the last generation.
However, the continued incrementalism of even progressive-speaking governments tells us that those in power are not interested in these outcomes.
There are good reasons people call for expanded abstinence-based services, despite the abundant evidence supporting alternative pathways.
For many, abstinence worked for them (often after multiple attempts), and they want the same access provided more easily for people.
Many parents are at their wits’ end with youth who use drugs and turn to the only solution on offer: residential treatment.
Quite often, I hear from people exhausted after giving up their living rooms to unhoused friends or family members. Inpatient and sober living facilities offer temporary housing for those willing to pause — or hide — their drug use.
Having failed to address the housing crisis, governments pass the buck to individuals, who are provided few options beyond privatized addiction facilities to temporarily house their loved ones.
Data on factors informing success rates of residential treatment and detox is not publicly disclosed by any province in Canada that I could find.
For those who use drugs to endure hard living conditions (such as houselessness or ongoing abuse), institutionalization is unlikely to solve anything as the root causes remain.
Conversely, someone who has their basic needs met and is looking to stop using drugs might just need a short, supported break to achieve lasting abstinence. The Alberta government’s flagship Red Deer Recovery Community is based on a six-to-12-month residency.
There is a real societal tendency to warehouse people rather than support them in their lives as they exist — as clear an example of stigma as you can find. There is also an emerging strain of paternalism that insists stigma can solve drug poisoning. The National Post opinion pages continue to adopt this point, which was propagated at Alberta’s safe supply committee by Michael Shellenberger echoing the chief of staff to the Alberta premier, Marshall Smith.