A continuing medical education course for Massachusetts physicians carried an inviting title: Empowering Recovery from Opioid Use Disorder: Transforming Lives and Enhancing Professional Fulfillment. The Massachusetts Board of Registration in Medicine helped fund it. Physicians need opioid and pain-management education to renew their licenses. The same board establishes the requirement, supports an approved course, and disciplines physicians whose clinical judgment strays beyond the accepted boundary.
The regulator has stepped onto the field. It is funding the coaching, defining the plays, and policing physicians who question the game. A regulator should judge whether a doctor has practiced competently and ethically. It should not dictate the governing theory of addiction, particularly when that theory remains contested.
The course’s fourth objective exposed its purpose: “Overcome hesitancy to treating people with opioid use disorder.” Hesitancy was presented as a defect in the physician. The possibility that a doctor might have sound reasons for avoiding long-term opioid maintenance received no serious place.
The doctrine began in the brain. Chronic opioid use alters receptors, tolerance, dopamine activity, craving, and withdrawal. These changes are real. They do not settle the argument. Human brains also change with grief, love, unemployment, divorce, exercise, and religious conversion. Neurochemistry moves as life moves. Naming the chemistry does not convert every experience into a disease.
In 1965, Vincent Dole, Marie Nyswander, and Mary Jeanne Kreek proposed that heroin addiction involved a metabolic disorder requiring indefinite chemical correction. The underlying defect was never identified. Still, the analogy endured: methadone was to the addict what insulin was to the diabetic.
That comparison sounds scientific because insulin replaces a substance the diabetic cannot produce. Remove insulin from a person with type 1 diabetes, and he may die. Remove heroin from an addicted person, and he suffers a severe but ordinarily survivable withdrawal. We treat dangerous alcohol withdrawal by removing alcohol under medical supervision. No hospital maintains an alcoholic with a measured morning glass of vodka.
The insulin analogy can also be tested geographically. If methadone corrected a stable metabolic deficiency, comparable patients should require roughly comparable amounts across state lines. Human biology does not consult a legislature. Yet methadone use varies enormously among states. My analysis found that overdose burden did not best predict a state’s consumption pattern. Prescriber density did. Where more clinicians prescribed methadone or buprenorphine, more of the drugs were dispensed.
That pattern resembles a treatment culture and a supply system more than biological replacement.
The course devoted 83 minutes to opioid treatment without explaining how a patient might stop taking the maintenance drug. Its slide on detoxification cited research from 1977, 1996, and 2005. These studies did not examine the method I used during eight years of practice: a structured 16-week taper, dose reductions near one percent per day, weekly visits, scored withdrawal assessments, and the patient’s rebuilding his life around an intended exit.
If nobody studied that method, old studies of brief or unstructured detoxification cannot prove it fails.
The vocabulary tells the story. A patient who remains on an opioid agonist for twenty years counts as retained in treatment. A patient who stops naltrexone, an antagonist that produces neither euphoria nor opioid dependence, may count as poorly retained. The first remains attached to a clinic; the second leaves. Under this measure, the drug that keeps the patient becomes successful. The drug that permits his departure performs poorly.
The economics follow the metric. Methadone and buprenorphine maintenance form a multibillion-dollar American industry, much of it financed by Medicaid and Medicare. Payment commonly follows the patient and continues with treatment. Once the system gets paid by the patient-day, every institutional incentive favors enrollment and retention. Graduation ends the revenue.
No conspiracy is necessary. People and institutions respond to payment.
Harm reduction has value at the edge of death. Fentanyl test strips, naloxone, supervised-use advice, and telephone monitoring can keep a man alive through the night. A living man can recover tomorrow. Yet emergency survival has become the ceiling of the system’s ambition. We have built an infrastructure to help a man survive tonight’s drug use; we have built almost nothing to bring him to a Tuesday when he no longer needs the drug, the clinic, or the vocabulary of permanent disease.
Recovery should include an exit. A treatment system that cannot describe one has confused maintenance with medicine and retention with success.
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