External evidence against using less-than complete abstinence as a primary outcome in addiction

Abstract

Addiction" is a complex neurobiological process of hedonic dysregulation. It is characterized in humans by compulsive use of substances, loss of control over the quantity consumed, and continued use despite the harm caused by the substance. Addicted individuals are prone to relapse that appears to be related to reexposure to the addicting substances, substance-related cues, and psychosocial stressors [1]. In this process, initial impulsivity is replaced by compulsivity [1]. The traditional method of treatment for addiction in the United States involves twenty-eight days of residential treatment. The follow-up recommendations by treatment centers generally amount to participation in twelve-step meetings. There is little financial incentive for rigorous follow-up in this model and the recovery rates following such treatments are unknown. Even if very generous definitions of success are applied, recovery rates remain low. However, for physicians, well-documented recovery rates following their initial residential treatment experience are high. Additionally, there is a movement in the field of addiction medicine to employ "Medication Assisted Treatment" (MAT). For example, its advocates recommend the use of medications such as naltrexone (Vivitrol ® ).The proponents of these medications, however, use curious outcome measures, rather than complete abstinence, to demonstrate their efficacy. This paper reviews and utilizes the neurobiology of addiction to compare and contrast the outcomes in different populations. It also reviews the outcome data on Vivitrol in particular. We believe that a clear understanding of the neurobiology of addiction is essential to understanding and correcting the vast outcome differences in various patient groups.