How Questioning Medication-First Addiction Treatment Made Me a Heretic
Questioning addiction treatment orthodoxies shouldn’t lead to academic exile
I am an experimental psychologist, and my goal throughout my career has been and still is to find the truth and to teach my students to do the same. How do we do that in science? We disprove our own and others’ faulty claims and methodically arrive at truth. Or at least that’s the way it’s supposed to work.
My own research is in the area of addiction. I want to eradicate it—a big goal, especially as vast amounts of money and manpower have been invested in addressing addiction without actually reducing the problem. So, there is much work to be done.
The scientist in me wants to “build a better mousetrap”—to find the best ways to reduce dependence on substances. I particularly want to investigate the effectiveness of non-pharmacological treatments, methods such as intentionally increasing the patient’s interpersonal connections. However, whenever I question the status quo, which involves using medication as the (almost) universally recommended, “evidence-based” treatment for addiction, I am accused of endangering people, stigmatizing addicts, and bringing up questions that have already been answered.
But those questions have not been answered. In fact, the questions haven’t even really been asked yet because the “evidence” base is comprised of studies comparing one medication to another, rather than comparing medication to non-pharmacological interventions.
Unfortunately, when it comes to treating addiction, there is an ironclad orthodoxy. Research funding for additional treatment almost always requires medication to be provided to patients. Treatment guidelines call a failure to medicate unethical. And trying to publish articles questioning medical intervention for addiction has been nearly impossible for me and my colleagues.
Seeking effective treatment alternatives threatens several multibillion-dollar industries—from Big Pharma to the prison system, from lab testing to treatment centers. Those protecting these industries are far better positioned to lobby and to curry favor with funders, publishers, and guideline gatekeepers. Is that what is happening or is their ideology just so strong that they truly can’t fathom any alternative being viable, let alone superior?
I would like to see head-to-head comparisons of treatments. Let the chips fall where they may. Let the most effective treatments win. But because I dare to question the pharmacological bias, I feel as if I am left (or being sent) outside the camp.
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Dr. Clements, I am a retired professor of neuroscience from the University of Massachusetts with expertise in the neurochemistry of abused substances. I am also the lead author of an advanced undergrad/beginning grad level textbook in psychopharmacology. I agree with several of your points, including the heavily medication-oriented policies of federal granting agencies as well as the difficulty (in all areas of science and medicine) of going against a so-called consensus position. On the other hand, I think two points need to be made about some of your other concerns. First, although I fully agree about the limitations of medications used in the treatment of substance use disorders (see, for example, Negus & Banks, Confronting the challenge of failed translation in medications development for substance use disorders, Pharmacol. Biochem. Behav., 210, 173264, 2021), I think you'd agree that medications can play an important role in quelling patient drug cravings while undergoing some sort of behavioral therapy. Second, it's not clear from your post that you're aware of the many published studies and reviews on the efficacy of behavioral therapies (including but not limited to cognitive behavioral therapy), either alone or with medication, in treating substance use disorders. Several papers that I came up with after a brief search are as follows: (1) Kim et al., Efficacy of cognitive behavioral therapy for stimulant use disorders: a systematic review and meta-analysis, Front. in Psychiatry, 16, 1695702, 2025; (2) Boness et al., An evaluation of cognitive behavioral therapy for substance use disorder: A systematic review and application of the Society of Clinical Psychology criteria for empirically supported treatments, Clin. Psychol. (New York), 30(2), 129-142, 2023; (3) Magill et al., Efficacy of cognitive behavioral therapy for alcohol and other drug use disorders: Is a one-size-fits-all approach appropriate? Subst. Abuse Rehabil., 14, 1-11, 2023; (4) Ray et al., Combined pharmacotherapy and cognitive behavioral therapy for adults with alcohol or substance use disorders. A systematic review and meta-analysis. JAMA Network Open, 3(6), e208279, 2020. It's also worth exploring some of the proposed behavioral (as opposed to "disease") models of substance use disorder (i.e., addiction). One example that I find interesting is the approach taken by Banks and Negus in their paper entitled Insights from preclinical choice models on treating drug addiction, Trends Pharmacol. Sci., 38, 181-194, 2017. I hope that the above cited reviews help clarify the current state of the field regarding non-pharmacological treatments of substance use disorders.
My own anecdotal stories of trying to have various forms of a lit review outlining some of the drawbacks of addiction treatment medications is what drove me to write this paper. I also have a colleague who does the "controversial research" on tapering buprenorphine for women who are pregnant and want to be tapered. It is controversial because it goes against current ACOG guidance (which has a very shaky scientific underpinning), but it is remarkably successful at preventing neonatal abstinence syndrome (NAS). He eventually has gotten his research published in lower tier medical journals, but was pulled from presenting it at ACOG after having been accepted. That was not because the science was bad, but because it differed with the current guidance. Others at the University of Tennessee had done similar research finding the same effect. The primary driver of that research finally retired because of the exhausting treadmill of trying to power through the gatekeeping.
I have also been looking into funding more deeply. I frequently try to find grants to support the investigation of alternatives or additions to medication for my own research. I would love to see scientifically sound studies comparing various treatment modalities to determine effectiveness. That is nearly impossible without funding programs that test abstinence as a goal. Currently, SAMHSA's State Opioid Response (SOR) Grants explicitly mandate that grant recipients must ensure patients have access to all three FDA-approved forms of MOUD: methadone, buprenorphine, and injectable naltrexone. Section 501 of the Public Health Service Act (42 U.S.C. § 290aa) gives SAMHSA the legal authority to do this. The latitude in this law would allow SAMHSA to fund the study of abstinence promoting research, but it currently doesn't. Why?