have organizational structures, staffing patterns and other resources that are neither physician centered nor involve physician delivery or oversight (Substance Abuse and Mental Health Services Administration, 2002). Even the opioid treatment programs that use methadone or levo-alpha acetyl methadol (LAAM) generally have minimal medical oversight, and most lack even rudimentary medical diagnostic or primary care delivery capability (D’Aunno et al., 1999). The absence of medical staff poses a barrier to the adoption of new medications in specialty addiction treatment settings.

In order to provide immunotherapies and sustained-release formulations in specialty addiction treatment settings, substantial additional resources would be required to integrate medical services and medical personnel in these settings. Moreover, immunotherapies, particularly monoclonal antibodies, will need to be administered in a medical setting where emergency medical treatment is available.

Philosophy

Specialty treatment settings may also be limited in their ability or interest in adopting new pharmacotherapies due to philosophical resistance. Most addiction treatment staff have been trained in one or more psychosocial treatment approaches (e.g., 12 steps; cognitive behavioral therapy, relapse prevention). They understand these approaches, know they work with many patients, and have little motivation to use medication. Lack of training and understanding of the effects and side effects of addiction medications, and discomfort with the research supporting the use of medications, are additional barriers (Mark et al., 2000; Owen, 2002; Thomas, 2000; Thomas et al., 2003). Although the potential value of medications may be acknowledged, there may also be deep skepticism.

This philosophical difference emerges partly from a particular interpretation of the 12-step approach of Alcoholics Anonymous (AA). Although AA founder, Bill Wilson (1955), emphasized collaboration between 12-step programs and the medical profession, many 12-step programs developed a drug-free philosophy that extended even to psychoactive medications for major depression or other serious, nonsubstance related mental disorders, and many patients were pressured to stop all medications (Woody and McNicholas, this volume). The strong personal experiences of staff with recovery without the use of medications may have promoted opposition to the use of medication even when combined with psychosocial treatment. These antimedication biases have diminished, especially concerning patients with dual addiction and mental health diagnoses, but they are often still strong in the case of antiaddictive medications.



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