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?
Thanks for taking time to respond and think deeply about these issues with me. This gave me a chance to pull a few more of my thoughts together.
I do agree that medications have a place in treatment, a tool in the toolbox if you will, particularly at the time of entry into treatment. They are much safer than illicit drugs, and I do not want to throw the baby out with the bathwater.
I also am aware of a good bit of research supporting CBT, ACT, and contingency management that are quite effective treating SUD. However, there is very little funding for the study or implementation of such things. (See Galves et al. (2025) How Much is the National Institute of Mental Health Spending on Studying Psychotherapy? and Zilberstein et al. (2025) Off Balance: National Institute of Mental Health Funding Priorities in 2012 and 2020). Galves showed that in 2012 and 2020, 20% and 14% of the budget were spent of investigating treatment and 7% and 4% were spend on studies of psychotherapy. The lion's share of funding went to brain studies.
My frustrations usually come from a few things:
1. Being shut down when suggesting there are drawbacks to long-term medication reliance.
I have been told that asking those questions could cause someone in treatment to be less committed to staying in treatment and could make them feel stigmatized. The person at the end of the food chain who is being treated is my focus. I want to empower them with full knowledge of pros and cons and empower them to make choices for themselves without the medical community wooing or sometimes bullying them into a certain treatment regimen. I am a huge proponent of letting people know up front that these medications are difficult to stop using. I think that people should be offered the opportunity to taper off if they want to taper, and I don't mean someone saying "you can if you want, but it probably won't work." I mean having someone who supports them and encourages them, and has hope for them to succeed in whatever path they take.
Major drawbacks of MAT (AKA MOUD because we change the names of things frequently) I see that need to be publicized are:
- it is the major cause of neonatal abstinence syndrome (NAS also called NOWS because we change terms) in my area, and maybe most areas. We now know there are long-term (likely lifelong) effects of NAS and probably drug exposure that doesn't rise to the level of NAS. We could prevent a vast amount of NAS if we treated non-medically at least during pregnancy.
Shore, S., Lewis, N., & Olsen, M. (2023). Rise in neonatal abstinence syndrome rate is associated with increase in buprenorphine prescription numbers. Southern medical journal, 116(12), 930–937. https://doi.org/10.14423/SMJ.0000000000001634
Olsen M. (2020). Prevention of neonatal abstinence syndrome in an outpatient prenatal buprenorphine tapering program. Southern medical journal, 113(11), 553–558. https://doi.org/10.14423/SMJ.0000000000001164
- severity and length of withdrawal from methadone and buprenorphine, making it extremely difficult to stop using even if someone chooses to (more difficult to taper than the substances it is treating).
- the extremely high buprenorphine doses used for treatment (recommended entry dose has the morphine equivalent of 48 Lortab tablets per day). A 96 Lortab equivalent is common in my area. Yes, tolerance forces increased dosage over time, but that same tolerance isn't an issue if non pharmacological treatments are used.
- all medications have side effects, including MAT. One that concerns me is that those who are on anything that activates or blocks their opioid receptors are less likely to connect with people. There is a growing sentiment (and research base) that interpersonal connection predicts low/no problematic substance use. Is our treatment undermining our cure?
Torres N. (2019). Testing a neuro-evolutionary theory of social bonds and addiction: Methadone associated with lower attachment anxiety, comfort with closeness, and proximity maintenance. Frontiers in psychiatry, 10, 602. https://doi.org/10.3389/fpsyt.2019.00602
Toubia, T., & Khalife, T. (2019). The endogenous opioid system: Role and dysfunction caused by opioid therapy. Clinical obstetrics and gynecology, 62(1), 3–10. https://doi.org/10.1097/GRF.0000000000000409
2. A subset of people are trying to downplay abstinence as an acceptable goal of treatment, going so far as to say that using abstinence related terminology can be stigmatizing.
If eventual abstinence is not "allowed" as a goal, then it becomes less likely that those in the recovery field will have hope of that for their clients. The clients' self-efficacy is likely to be reduced. We know from decades of research that people rise or fall to the level of expectations.
I also take issue with stigma being seen as universally negative. Many times it is negative and introduces unfairness and discrimination, but other times it could actually be beneficial. For example, if social pressure assists someone to reduce or abandon risky substance use, the stigma might be worth it. Although this has fallen out of favor, take a look at social control theory.
Pfund RA, Peter SC, Swift JK, Witkiewitz K. Nonstigmatizing and Precise Terminology to Describe Processes and Outcomes in Addiction Medicine. J Addict Med. 2022;16(3):255-257. doi:10.1097/ADM.0000000000000885
Meadows DC, Moore KE, Taylor B, Lamuda P, Schneider J, Pollack H. Preference for Abstinence-Based Recovery and Public Stigma Toward Substance Use. Subst Use Misuse. 2025;60(10):1424-1433. doi:10.1080/10826084.2025.2501171
I appreciate Clements’ interesting piece, but I would like to see more evidence. Are there anecdotes of scholars like this being excluded from grants and publications? Is there systemic evidence of this bias?
Then we have the question of how to help address this problem. Ironically, one solution is precisely the opposite of what HxA urges: We need more scholar-activists. Clements is a social justice activist (“I want to eradicate” addiction). This is in no way incompatible with her being a scientist. It seems the solution is that we need more activists in the field who want to cure addiction, rather than people who view it as simply a job where one acquires grants from pharmaceutical companies.
The other solution is a little known aspect of the Shils Report at the University of Chicago, which says that scholars should be judged by the quality of their research rather than the quantity of money they generate from grants. This wouldn’t solve all the problems of groupthink, but it would help address the corrupting influence of corporate grants.
I don’t think he’s an activist. He simply wants to do research to find the most effective way to treat addiction. As someone who’s been on methadone, buprenorphine and now is in long term recovery without medication and who worked in the treatment industry around this time it switched from non medication treatment to medication assisted treatment, I think that research is needed.
Thanks Mark. I have heard so many stories from people who are thrilled to be off medication. I'm happy for you. I do think medication can be a tool, but it's not the only tool. I'm all about people having the ability to choose their path to recovery, but I want to be able to help people make informed decisions. We need to be able to conduct studies that compare treatments. If we do good science, we will find what is and is not effective. That's what I'm asking for.
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?
Jerrold,
Thanks for taking time to respond and think deeply about these issues with me. This gave me a chance to pull a few more of my thoughts together.
I do agree that medications have a place in treatment, a tool in the toolbox if you will, particularly at the time of entry into treatment. They are much safer than illicit drugs, and I do not want to throw the baby out with the bathwater.
I also am aware of a good bit of research supporting CBT, ACT, and contingency management that are quite effective treating SUD. However, there is very little funding for the study or implementation of such things. (See Galves et al. (2025) How Much is the National Institute of Mental Health Spending on Studying Psychotherapy? and Zilberstein et al. (2025) Off Balance: National Institute of Mental Health Funding Priorities in 2012 and 2020). Galves showed that in 2012 and 2020, 20% and 14% of the budget were spent of investigating treatment and 7% and 4% were spend on studies of psychotherapy. The lion's share of funding went to brain studies.
My frustrations usually come from a few things:
1. Being shut down when suggesting there are drawbacks to long-term medication reliance.
I have been told that asking those questions could cause someone in treatment to be less committed to staying in treatment and could make them feel stigmatized. The person at the end of the food chain who is being treated is my focus. I want to empower them with full knowledge of pros and cons and empower them to make choices for themselves without the medical community wooing or sometimes bullying them into a certain treatment regimen. I am a huge proponent of letting people know up front that these medications are difficult to stop using. I think that people should be offered the opportunity to taper off if they want to taper, and I don't mean someone saying "you can if you want, but it probably won't work." I mean having someone who supports them and encourages them, and has hope for them to succeed in whatever path they take.
Major drawbacks of MAT (AKA MOUD because we change the names of things frequently) I see that need to be publicized are:
- it is the major cause of neonatal abstinence syndrome (NAS also called NOWS because we change terms) in my area, and maybe most areas. We now know there are long-term (likely lifelong) effects of NAS and probably drug exposure that doesn't rise to the level of NAS. We could prevent a vast amount of NAS if we treated non-medically at least during pregnancy.
Shore, S., Lewis, N., & Olsen, M. (2023). Rise in neonatal abstinence syndrome rate is associated with increase in buprenorphine prescription numbers. Southern medical journal, 116(12), 930–937. https://doi.org/10.14423/SMJ.0000000000001634
Olsen M. (2020). Prevention of neonatal abstinence syndrome in an outpatient prenatal buprenorphine tapering program. Southern medical journal, 113(11), 553–558. https://doi.org/10.14423/SMJ.0000000000001164
- severity and length of withdrawal from methadone and buprenorphine, making it extremely difficult to stop using even if someone chooses to (more difficult to taper than the substances it is treating).
- the extremely high buprenorphine doses used for treatment (recommended entry dose has the morphine equivalent of 48 Lortab tablets per day). A 96 Lortab equivalent is common in my area. Yes, tolerance forces increased dosage over time, but that same tolerance isn't an issue if non pharmacological treatments are used.
- all medications have side effects, including MAT. One that concerns me is that those who are on anything that activates or blocks their opioid receptors are less likely to connect with people. There is a growing sentiment (and research base) that interpersonal connection predicts low/no problematic substance use. Is our treatment undermining our cure?
Torres N. (2019). Testing a neuro-evolutionary theory of social bonds and addiction: Methadone associated with lower attachment anxiety, comfort with closeness, and proximity maintenance. Frontiers in psychiatry, 10, 602. https://doi.org/10.3389/fpsyt.2019.00602
Toubia, T., & Khalife, T. (2019). The endogenous opioid system: Role and dysfunction caused by opioid therapy. Clinical obstetrics and gynecology, 62(1), 3–10. https://doi.org/10.1097/GRF.0000000000000409
2. A subset of people are trying to downplay abstinence as an acceptable goal of treatment, going so far as to say that using abstinence related terminology can be stigmatizing.
If eventual abstinence is not "allowed" as a goal, then it becomes less likely that those in the recovery field will have hope of that for their clients. The clients' self-efficacy is likely to be reduced. We know from decades of research that people rise or fall to the level of expectations.
I also take issue with stigma being seen as universally negative. Many times it is negative and introduces unfairness and discrimination, but other times it could actually be beneficial. For example, if social pressure assists someone to reduce or abandon risky substance use, the stigma might be worth it. Although this has fallen out of favor, take a look at social control theory.
Pfund RA, Peter SC, Swift JK, Witkiewitz K. Nonstigmatizing and Precise Terminology to Describe Processes and Outcomes in Addiction Medicine. J Addict Med. 2022;16(3):255-257. doi:10.1097/ADM.0000000000000885
Meadows DC, Moore KE, Taylor B, Lamuda P, Schneider J, Pollack H. Preference for Abstinence-Based Recovery and Public Stigma Toward Substance Use. Subst Use Misuse. 2025;60(10):1424-1433. doi:10.1080/10826084.2025.2501171
I appreciate Clements’ interesting piece, but I would like to see more evidence. Are there anecdotes of scholars like this being excluded from grants and publications? Is there systemic evidence of this bias?
Then we have the question of how to help address this problem. Ironically, one solution is precisely the opposite of what HxA urges: We need more scholar-activists. Clements is a social justice activist (“I want to eradicate” addiction). This is in no way incompatible with her being a scientist. It seems the solution is that we need more activists in the field who want to cure addiction, rather than people who view it as simply a job where one acquires grants from pharmaceutical companies.
The other solution is a little known aspect of the Shils Report at the University of Chicago, which says that scholars should be judged by the quality of their research rather than the quantity of money they generate from grants. This wouldn’t solve all the problems of groupthink, but it would help address the corrupting influence of corporate grants.
I don’t think he’s an activist. He simply wants to do research to find the most effective way to treat addiction. As someone who’s been on methadone, buprenorphine and now is in long term recovery without medication and who worked in the treatment industry around this time it switched from non medication treatment to medication assisted treatment, I think that research is needed.
Thanks Mark. I have heard so many stories from people who are thrilled to be off medication. I'm happy for you. I do think medication can be a tool, but it's not the only tool. I'm all about people having the ability to choose their path to recovery, but I want to be able to help people make informed decisions. We need to be able to conduct studies that compare treatments. If we do good science, we will find what is and is not effective. That's what I'm asking for.