The Great Paradox of Addiction Treatment
Balancing Patient Preference with Medical Safety
When it comes to addiction medicine, there is often an opposing tension between evidence-based treatment and patient preference. This is the provider’s paradox: the safest, most effective treatment is often NOT what the patient wants or is willing to accept.
What do we do then? Is some addiction treatment better than no treatment? In my opinion, the answer is always YES.
Patients who suffer from severe opioid use disorder often refuse inpatient stabilization and FDA approved medications for opioid use disorder (MOUD) like methadone or buprenorphine. They often want to start with outpatient counseling. Should we decline their plea for help because it comes with more risks? They might never come back…
Many patients on buprenorphine who struggle with ongoing intermittent illicit use will refuse inpatient admission for stabilization but are willing to continue outpatient appointments with buprenorphine continuation. Should we refuse to continue care, knowing that stopping their buprenorphine prescription will skyrocket their risk of death much higher?
This all or nothing approach risks alienating those who need our care the most. With the disease of addiction comes varying levels of patient insight and motivation. While lower level of care options may not be ideal for symptom severity, they can still be lifesaving. The alternative—abandoning the patient because they are not willing to follow the “gold standard” approach—will inevitably lead to overdose, disease progression, and death. At least with some treatment, folks have a fighting chance.
In 2024, The American Society of Addiction Medicine (ASAM) addressed this common treatment predicament head on by creating a new “person-centered considerations” dimension in their newest level of care decision making placement criteria. ASAM recognized that what patients are willing to do often contradicts the official medical recommendation. Accordingly, this new dimension formally incorporates patient willingness into formal treatment planning decisions.
ASAM gets it. Regulatory bodies, policymakers, and payors must also recognize that addiction treatment is not a one-size-fits-all model. Organizations willing to meet patients where they are—whether through harm reduction strategies, flexible treatment protocols, or nontraditional engagement methods—should be supported. A patient who is alive and engaged in some form of treatment, no matter how imperfect, is always better than a patient who is lost to the system entirely.
Respecting patient autonomy and self-determination is critical for effective and compassionate addiction care. When we give providers autonomy to treat addiction in ways that align with clinical judgment and patient willingness, we will save even more lives.
-Lauren
I am exploring how to design systems that provide humane support and today highlighted the story of Parys Lapper, a young teen whose death was fueled by a lack of individual and family-based supports in the face of an all-or-nothing ultimatum just like you describe. I'd be really interested in hearing what you think would be helpful at a systems level to provide the kind of support you and your patients need!