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The Myth of Tapering

It is unclear where the erroneous recommendation to taper during Medication Assisted Treatment (MAT) began, since no reputable authority on substance abuse treatment recommends tapering.  On the contrary, every professional organization involved in the field of addiction recommends long term treatment, not tapering.  The two primary textbooks, Principles of Addiction Medicine, published by the American Society of Addiction Medicine (ASAM), and The Textbook of Substance Abuse Treatment, published by the American Psychiatric Association, both clearly state that maintenance is the standard of care.

"The American Society of Addiction Medicine supports the principle that maintenance is most effective as a long-term modality."  "Treatment should be continued as long as the patient continues to benefit from treatment…"  "Maintenance continues until such a time that there is a reason to alter the treatment."  Principles of Addiction Medicine, 4th edition.

"There is no time requirement or restriction to the length of time patients can receive buprenorphine maintenance treatment.  In general, relapse to illicit opioid use and treatment dropout is high during opioid detoxification (tapering), such that opioid addiction is considered a chronic, relapsing disorder deserving ongoing treatment and monitoring much like other chronic medical diseases (e.g., diabetes mellitus).  Textbook of Substance Abuse Treatment.

Also, in a recent statement by the current president of ASAM, he again reiterated that MAT is treatment for a chronic disease, and tapering is to be avoided.Perhaps this myth has its origins in the federal government's attempts over 40 years ago to taper people off methadone.   "In the early 1970's, efforts to limit the duration of treatment and to cap the dose occurred initially at the federal level and later were initiated by some individual state methadone authorities."  Since that time numerous studies have uniformly validated the importance of continuing treatment indefinitely, and have clearly shown that tapering results in relapse.  "The known risks of discontinuing treatment, with predictable relapse… suggest that long-term –even indefinite—treatment is appropriate and even essential for a significant proportion of eligible patients." Principles of Addiction Medicine.

Again, addiction is a chronic disease, frequently requiring long term treatment like any other chronic disease.  To believe that it will suddenly go away on its own is like believing that diabetes will just go away if we quit treating it.  Both diabetes and addiction have strong genetic components, and a person’s genetics don’t change over time.  We must start looking at addiction like every other disease, as having genetic and environmental determinants, and approach it with the same attitudes and beliefs that we hold for other diseases, not the shame and blame that we currently inflict upon people with addiction.  People who suffer from this disease did not choose it any more than someone who gets cancer, and we need to show them the same compassion and understanding, and provide them with the same scientific evidence based treatment that we provide for every other disease that we encounter in the field of medicine.  Treatment based on opinion and conjecture has been shown over and over again to be ineffective, or worse, lethal.  Furthermore, ineffective treatment destroys families, reduces employment, and results in higher criminal recidivism and increased costs to society.  It is time we get over our preconceived erroneous opinions and focus on the scientific data to provide appropriate care for this disease, as we do every other disease in the field of medicine.

 

Dr. Vance Shaw, MD, FASAM

Board Certified by the American Board of Addiction Medicine

Revised May 2017