The Potential Fatal Flaw in Andrew Yang’s Opioid Policy

Mandating overdose patients to treatment centers is not evidence-based.

Posted Oct 22, 2019

The overdose crisis in North America is complicated and multi-pronged in its causes and solutions. Opioid addiction has rightly become a presidential election topic.

Among the Democratic candidates, Andrew Yang’s opioid policy for addressing the crisis is particularly worthy of attention. It includes a variety of proposals, such as increasing addiction treatment funding, taking steps to reduce opioid prescribing, decriminalizing small amounts of opioids for personal use, and perhaps most controversially, sending overdose patients to “mandatory treatment centers for three days to convince them to seek long-term treatment.”

As a clinical psychologist who specializes in addiction, I think this policy is a mixed-bag with mixed messages. A strong case can be made for drug decriminalization and I commend Yang for his aim to “destigmatize medication-based treatment options.” The potential fatal flaw of Yang’s policy, however, is that mandating overdose patients to treatment centers arbitrarily for three days is neither evidence-based nor sensible. 

Pixabay
Source: Pixabay

It is not evidence-based for two main reasons. First, and most straightforwardly, there have been no such opioid treatment protocols proposed, let alone evaluated in the scientific literature. It is dangerous to propose treatment protocols in the absence of evidence because the treatment might not only be ineffective, it could also produce harmful effects.

Secondly, the evidence that we do have suggests that the best and first-line treatment for opioid addiction is opioid agonist therapy (OAT), such as the use of suboxone and methadone medications. While some research shows that the addition of particular kinds of psychotherapy and counseling to OAT can in some cases make treatment even more effective, other research shows no such clear evidence. This means that the current evidence is mixed as to whether the addition of psychotherapy and counseling to OAT is needed to reduce opioid use.

That said, I want to be clear about exactly what these mixed findings mean. They mean that forcing a person to go to counseling after an overdose is not supported by the evidence—instead, the evidence supports increasing access to OAT. The evidence does not mean that psychotherapy and counseling are useless and not beneficial in the treatment of opioid addiction—instead, the evidence supports the idea that particular kinds of psychotherapy and counseling should be delivered whenever possible, but that they should be considered second to OAT. 

Mandating overdose patients to treatment centers for three days with a view “to convince them to seek long-term treatment” is also not sensible and is often counter-therapeutic. While there is evidence to show that a brief form of motivational counseling can sometimes be beneficial to people with, and at risk for opioid use problems, the very nature of this kind of counseling does the opposite of “convincing” anyone to do anything.

Instead, this kind of treatment emphasizes therapeutic ideas such as personal control, awareness building, and strengthening commitment to make changes. As a general rule, one risk of forcing a person to do anything is the activation of a psychological phenomenon called psychological reactance, which means that if a person is demanded to do something, there can be a temptation to resist or do the opposite.

Andrew Yang should be commended for attempting to address opioid addiction by focusing on both supply and demand. Based on the evidence, however, mandating overdose patients to treatment is flatly unethical. While one of Yang’s aims is to “destigmatize medication-based treatment options,” I am concerned that mandating overdose patients to treatment centers will have the opposite effect.

People with opioid addiction require access to opioid agonist therapies as a necessary condition of treatment. Treatment can then be potentially enhanced by adding other services. While Yang’s heart is likely in the right place, the path to hell is paved with good intentions. Instead, we need to follow the evidence.