Meet the Drug Rehab Celebrity Dispensing a Dangerous Brand of Intolerance

The following article first appeared on Substance.com: 

In a better world, there would be no conflict between abstinence-based treatment and harm reduction: As in other types of medicine, addiction care would occur on a continuum. Just as you don’t see cancer doctors blogging that radiation is a “con” and only chemo should be used in all cases, you wouldn’t see addiction counselors making a similar case that abstinence should always be used, never maintenance.

Unfortunately, thanks to the likes of Bob Forrest, that’s not the world we live in. Forrest, who identifies himself on his website as the “longtime partner of Dr. Drew,” now runs his own treatment program, Acadia Malibu. It’s hard to believe, but yes, a man who worked on Dr. Drew’s Celebrity Rehab actually advertises this fact to sell addiction services—despite the show having a mortality rate of nearly 13% among its “patients.”

Forrest opposes maintenance treatment—even though three of the five patients who died after their season on the show lost their lives to opioid overdose or its complications, which could have been prevented if they had been given support for maintenance, rather than told abstinence is the One True Way.

Nonetheless, here’s what Forrest—after noting, “I thought of calling this blog ‘The Open-Minded Report’”—writes about harm reduction:

“It’s a con in my opinion. I have seen the suffering and degradation it causes: the confusion it brings to the 12-step community about who is sober and who is not; the irrational fear of detox, where the list of medications designed to help you avoid actually experiencing any withdraw symptoms grows longer and longer every year; and just generally, the lies and danger and horror it is causing. The medical profession and pharmaceutical industries drive the use of Suboxone and Subutex. This is code for ‘profitable to doctors and drug companies.’”

Nearly everything about this paragraph is wrong. For one, if harm reduction—by which he means opioid maintenance here—is a “con,” why is it endorsed by every major public health organization that has investigated the issue, from the Centers for Disease Control and the National Institutes of Health in the US to the National Institute for Health and Care Excellence in the UK and the World Health Organization?

Why does the Cochrane Collaboration—an independent organization widely viewed as producing the highest-quality evidence on which to base medical decisions—say this about methadone: “It retains patients in treatment and decreases heroin use better than treatments that do not utilize opioid replacement therapy,” while concluding of 12-step programs that “no experimental studies unequivocally demonstrated the effectiveness of AA or [12-Step Facilitation] approaches for reducing alcohol dependence or problems”?

And why does research show that patients who leave methadone treatment double their risk of dying—and quintuple their risk of overdose death if they are injection drug users? Why do studies consistently find death rates among addicted people in methadone treatment to be about one-quarter or one-third the rate of those not on maintenance? Even if Forrest relies only on anecdote, not data, his own experience with Celebrity Rehab deaths clearly bears this out.

OK, so it’s clear that Forrest is on the fringes here, ignoring both an overwhelming international consensus on best practices and the evidence of his own eyes. Let’s move on.

Is there any truth to the idea that maintenance treatments are simply a profit center for doctors and drug companies? While some money is being made, a look at the actual history of maintenance makes evident that if this is a pharma conspiracy, it’s an extremely strange one, because the US government basically had to pay drug companies to participate in it.

Let’s start with methadone. It’s a generic drug, long off patent and therefore definitely not of current interest to Big Pharma. As an addiction treatment, methadone was developed by Vincent Dole and Marie Nyswander of Rockefeller University in the mid-1960s—starting with money scraped together mainly from the government of New York City, not drug companies.

At first, virtually all methadone treatment was funded by the federal government as an anti-crime measure—and while there certainly have been unscrupulous providers, that’s linked far more to the stigma of addiction, and the lack of oversight of the care addicted people actually get for the money spent on us, than to any drive for pharmaceutical profit related to selling methadone.

What about Suboxone? It, too, was first studied as an addiction treatment, by the government—in fact, there was so little commercial interest in it that the National Institute on Drug Abuse had to push the FDA to give it “orphan” status in order to get the company that now makes it to enter the market. As Nancy Campbell writes in Discovering Addiction: The Science and Politics of Substance Abuse Research, “Lack of coordination between public and private interests delayed development far longer than the notoriously slow FDA approval process. To bring ‘bupe’ to market, NIDA worked to stimulate private interest.”

In other words, we have Suboxone despite the disinterest of pharma in the addiction market—not because it saw dollar signs when it looked into our eyes. While Reckitt Benckiser did ultimately profit from the drug, this is not a scandal like the overselling of antipsychotic medications, for which every single manufacturer has paid at least multimillions, and sometimes billions, of dollars in fines for misleading marketing. Indeed, it’s an example of a drug that is doing precisely what a drug is supposed to do: restoring health more often than harming it.

Of course, it’s not completely wrong to say that there is an excess of shady doctors in the Suboxone business—but again, the reason for this is that addicted people are, to put it mildly, not popular with physicians. Those who have the choice not to work with us generally make that decision whenever they can—because of both the stigma and the legal scrutiny that maintenance treatment for addiction brings.

All of this is not to say that everyone who has ever had an opioid addiction should be on maintenance: I am personally an example of someone who is not. But good medical practice is about finding the right treatment for the right person—not prescribing the same therapy at the same dose for every patient with every variant of the disorder in which you supposedly specialize.

Finally, I have to add that it’s laughable that someone like Forrest would claim that maintenance proponents are scaring people away from abstinence by raising fear about withdrawal—when on Celebrity Rehab, patients were brutally detoxed in the most uncomfortable way possible.

Need I remind him that one person who later died of an overdose actually became psychotic during withdrawal on the show and another, who later committed suicide, suffered a seizure? Actual experts say that neither symptom should have been allowed to emerge in appropriate medical treatment with slow, careful detox—but this is the picture of withdrawal that the supposed abstinenceadvocate presented to the world.

There’s truly no need for abstinence and harm reduction advocates to be at each other’s throats: Both forms of treatment are needed and belong in the continuum of care. Not every person addicted to opioids needs lifelong maintenance—but some do; likewise, while some people benefit greatly from 12-step participation, others don’t. We can, and should, all get along here, to paraphrase Rodney King, another patient who died after Celebrity Rehab.

While there is room for many different approaches in addiction treatment, we’ve got to start being intolerant of this absurd and often deadly intolerance.