Jonathan D. Avery - The Opioid Epidemic and the Therapeutic Community Model: An Essential Guide

Opioids have been written into our contemporary American zeitgeist, overflowing the prescription pads that have flooded medicine cabinets and illicit marketplaces with up to 80 scripts per 100 persons at the peak of the crisis we have collectively faced since the turn of the twenty-first century [].

In 2017, 4.2% of the United States general population has been exposed to opioids in a way not directed by a prescribing clinicianincluding use without a prescription and use in greater amounts, more often, or for longer periods than directed [].

In the United States, OUD and its associated morbidity and mortality have received increasing attention from national public health authorities, medical professional organizations, federal and local government, and the lay press over the past decade. Contemporary OUD is most commonly associated with prescription opioid usenow threefold more frequent than OUD associated with heroin useand prescription opioid overdose deaths have quadrupled between 1999 and 2011, continuing to rise to a peak of 72,000 total drug overdose deaths per year in 2017.

This opioid epidemic, or crisis, has motivated a series of federal responses, including the Comprehensive Addiction and Recovery Act ( CARA) of 2016 [].

However, a significant group continues opioid use with its grave risks despite these first-line treatments, marking a population with treatment-resistant opioid use disorder for whom additional interventions are required. For some patients, relative medical contraindications or aversions to one or all of the available medications also limit their ability to benefit from MAT.

Further, the current system of care wherein MAT is delivered emphasizes short-term rehabilitation, with 30- or 60-day lengths of stay ( LOS) being most common. This is problematic for the treatment-resistant population in light of the multiply-replicated finding that greater LOS improves substance use-related outcomeswith a likely inflection point at 90 days and continued benefit with even longer treatment for more severely impaired individuals [].

The therapeutic community ( TC) is a treatment modality that addresses OUD via mechanisms of action that differ from MAT and other common interventions currently available in the United Statesincluding longer LOS , cognitive schema change, increased mentalization capacity, social learning, and educational/occupational habilitation. TCs may either complement current standards of care or serve as monotherapy for patients with severe, treatment-refractory OUD [].